Provider Demographics
NPI:1306476312
Name:LANE, TWANDA
Entity type:Individual
Prefix:MRS
First Name:TWANDA
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4118 JEFFERSON DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-4558
Mailing Address - Country:US
Mailing Address - Phone:586-995-7335
Mailing Address - Fax:
Practice Address - Street 1:4118 JEFFERSON DR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-4558
Practice Address - Country:US
Practice Address - Phone:586-995-7335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI05Medicaid
MIMEDICAIDEOtherDIRECT BILLING