Provider Demographics
NPI:1932541562
Name:LANE, KRISTEN G (NP)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:G
Last Name:LANE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:
Other - Last Name:GOODIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1150 GOLDEN WAY
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-7712
Mailing Address - Country:US
Mailing Address - Phone:706-612-9401
Mailing Address - Fax:706-612-9420
Practice Address - Street 1:1150 GOLDEN WAY
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7712
Practice Address - Country:US
Practice Address - Phone:706-612-9401
Practice Address - Fax:706-612-9420
Is Sole Proprietor?:No
Enumeration Date:2013-07-24
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN194082363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0031375748Medicaid
GARN194082OtherRN NUSING LICNESE NUMBER
GA202I500020OtherMEDICARE