Provider Demographics
NPI:1124718556
Name:LANE, BOBBY (LMT, RN)
Entity type:Individual
Prefix:
First Name:BOBBY
Middle Name:
Last Name:LANE
Suffix:
Gender:M
Credentials:LMT, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7832 ROYAL LN APT 112
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-3724
Mailing Address - Country:US
Mailing Address - Phone:214-998-5085
Mailing Address - Fax:
Practice Address - Street 1:7832 ROYAL LN APT 112
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-3724
Practice Address - Country:US
Practice Address - Phone:214-998-5085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX883861163W00000X
TXMT029279163WM1400X, 225700000X
NA171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No163W00000XNursing Service ProvidersRegistered Nurse
No163WM1400XNursing Service ProvidersRegistered NurseNurse Massage Therapist (NMT)
No171400000XOther Service ProvidersHealth & Wellness Coach