Provider Demographics
NPI:1811433774
Name:LANE, LAVICA (LM, CPM)
Entity type:Individual
Prefix:
First Name:LAVICA
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 DALWORTH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-5545
Mailing Address - Country:US
Mailing Address - Phone:972-263-0299
Mailing Address - Fax:972-642-4171
Practice Address - Street 1:814 DALWORTH ST
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-5545
Practice Address - Country:US
Practice Address - Phone:972-263-0299
Practice Address - Fax:972-642-4171
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-16
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX99284176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife