Provider Demographics
NPI:1528326899
Name:LANE, KIM MARIE (MOT)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:LANE
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2860
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88311-2860
Mailing Address - Country:US
Mailing Address - Phone:575-437-3351
Mailing Address - Fax:575-437-2622
Practice Address - Street 1:2351 INDIAN WELLS RD
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-4607
Practice Address - Country:US
Practice Address - Phone:575-439-1397
Practice Address - Fax:575-437-2622
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2919225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist