Provider Demographics
NPI:1902171861
Name:LANE, CAROL (PTA)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:PTA
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 1648
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:VA
Mailing Address - Zip Code:22572-1648
Mailing Address - Country:US
Mailing Address - Phone:804-333-8222
Mailing Address - Fax:
Practice Address - Street 1:4562 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:VA
Practice Address - Zip Code:22572-3141
Practice Address - Country:US
Practice Address - Phone:804-333-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306603234225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant