Provider Demographics
NPI:1366807315
Name:LANE, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
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 1:5501 W HILDEBRAND BLVD APT B100
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99338-1124
Mailing Address - Country:US
Mailing Address - Phone:509-551-8572
Mailing Address - Fax:
Practice Address - Street 1:4791 W VAN GIESEN ST # B
Practice Address - Street 2:
Practice Address - City:WEST RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99353-5085
Practice Address - Country:US
Practice Address - Phone:509-967-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60507628225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist