Provider Demographics
NPI:1104470772
Name:LANE, TINA NICHOLE (FNP)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:NICHOLE
Last Name:LANE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SW LONGVIEW BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64081-2116
Mailing Address - Country:US
Mailing Address - Phone:913-215-5008
Mailing Address - Fax:
Practice Address - Street 1:400 SW LONGVIEW BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64081-2116
Practice Address - Country:US
Practice Address - Phone:913-215-5008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO135267163WE0003X
MO2019043201363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily