Provider Demographics
NPI:1366189862
Name:LANE, COURTNEY ELIZABETH (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ELIZABETH
Last Name:LANE
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:ELIZABETH
Other - Last Name:GUTIERREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:618 E ROYAL PALM SQ S
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-3638
Mailing Address - Country:US
Mailing Address - Phone:623-633-1858
Mailing Address - Fax:
Practice Address - Street 1:140 N LITCHFIELD RD STE 110
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-1226
Practice Address - Country:US
Practice Address - Phone:602-256-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ274684363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care