Provider Demographics
NPI:1154376192
Name:LANE, KELLY (PAA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:PAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5445 MERIDIAN MARK RD STE 340
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-4766
Mailing Address - Country:US
Mailing Address - Phone:404-785-5650
Mailing Address - Fax:404-785-5610
Practice Address - Street 1:5445 MERIDIAN MARK RD STE 340
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-4766
Practice Address - Country:US
Practice Address - Phone:404-785-5650
Practice Address - Fax:404-785-5610
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA3001367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100001433FMedicaid
GA100001433FMedicaid
GA32BBBHQMedicare ID - Type Unspecified