Provider Demographics
NPI:1316325467
Name:LANE, MIKELLA RENEE
Entity type:Individual
Prefix:
First Name:MIKELLA
Middle Name:RENEE
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 1:5802 TOWNSEND PL
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4143
Mailing Address - Country:US
Mailing Address - Phone:307-256-6933
Mailing Address - Fax:
Practice Address - Street 1:5802 TOWNSEND PL
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4143
Practice Address - Country:US
Practice Address - Phone:307-256-6933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-09
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY171M00000X
251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251C00000XAgenciesDay Training, Developmentally Disabled Services