Provider Demographics
NPI:1104469485
Name:LANE, LOUISE
Entity type:Individual
Prefix:
First Name:LOUISE
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 DECKER AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-2201
Mailing Address - Country:US
Mailing Address - Phone:917-829-1625
Mailing Address - Fax:
Practice Address - Street 1:130 W KINGSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-3904
Practice Address - Country:US
Practice Address - Phone:718-584-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-19
Last Update Date:2019-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3747A065OXOtherVA HOSPITAL BRONX