Provider Demographics
NPI:1194901058
Name:LANE, BRANDI LYNN (CRNA)
Entity type:Individual
Prefix:MRS
First Name:BRANDI
Middle Name:LYNN
Last Name:LANE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2024 SHORES AVE
Mailing Address - Street 2:
Mailing Address - City:CAVE SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72718-8434
Mailing Address - Country:US
Mailing Address - Phone:918-527-4824
Mailing Address - Fax:866-635-3634
Practice Address - Street 1:3394 N FUTRALL DR STE 2
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-3937
Practice Address - Country:US
Practice Address - Phone:918-527-4824
Practice Address - Fax:866-635-3634
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-10
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0085276367500000X
ARC002958367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200130410AMedicaid
AR274092YJX9Medicare PIN