Provider Demographics
NPI:1962884171
Name:LANE, GWENDOLYN (CRNP)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4035 CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212-1666
Mailing Address - Country:US
Mailing Address - Phone:412-478-5539
Mailing Address - Fax:
Practice Address - Street 1:4035 CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15212-1666
Practice Address - Country:US
Practice Address - Phone:412-478-5539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP013863364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health