Provider Demographics
NPI:1285706713
Name:LANE, KIMBERLY ANN (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:LANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 CHURCH ST SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0340
Mailing Address - Country:US
Mailing Address - Phone:612-625-8400
Mailing Address - Fax:612-625-1434
Practice Address - Street 1:410 CHURCH ST SE
Practice Address - Street 2:BOYNTON HEALTH SERVICE
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0340
Practice Address - Country:US
Practice Address - Phone:612-625-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30134207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA94482Medicare UPIN