Provider Demographics
NPI:1811633845
Name:LANE, CRYSTAL DAWN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DAWN
Last Name:LANE
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:969 S PINEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-7031
Mailing Address - Country:US
Mailing Address - Phone:417-350-8236
Mailing Address - Fax:
Practice Address - Street 1:12811 KENWOOD LN STE 202
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-5646
Practice Address - Country:US
Practice Address - Phone:239-537-9646
Practice Address - Fax:239-236-0866
Is Sole Proprietor?:No
Enumeration Date:2022-05-11
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11029121363LP0808X
AR220223363LP0808X
MO2022017504363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL120758800Medicaid
MO420109430Medicaid
AR284170758Medicaid