Provider Demographics
NPI:1366620205
Name:LANE, CARMEN
Entity type:Individual
Prefix:MS
First Name:CARMEN
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 1:6333 75TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98516-9512
Mailing Address - Country:US
Mailing Address - Phone:360-280-0888
Mailing Address - Fax:
Practice Address - Street 1:6333 75TH AVE NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98516-9512
Practice Address - Country:US
Practice Address - Phone:360-280-0888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-02
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024838174400000X
WA74834174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist