Provider Demographics
NPI:1104550664
Name:LANE, KERRI MICHELLE (RN, BSN, FNP-C)
Entity type:Individual
Prefix:
First Name:KERRI
Middle Name:MICHELLE
Last Name:LANE
Suffix:
Gender:F
Credentials:RN, BSN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:155 FALCON TRL
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-9732
Mailing Address - Country:US
Mailing Address - Phone:573-421-2181
Mailing Address - Fax:
Practice Address - Street 1:1723 BROADWAY ST STE 315
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-4556
Practice Address - Country:US
Practice Address - Phone:573-519-4960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022026217363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner