Provider Demographics
NPI:1902949258
Name:LANIER, MANDY LYNNETTE (OD)
Entity Type:Individual
Prefix:MS
First Name:MANDY
Middle Name:LYNNETTE
Last Name:LANIER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 STATE FARM RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-4738
Mailing Address - Country:US
Mailing Address - Phone:828-264-0042
Mailing Address - Fax:828-264-8612
Practice Address - Street 1:610 STATE FARM RD
Practice Address - Street 2:SUITE A
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-4738
Practice Address - Country:US
Practice Address - Phone:828-264-0042
Practice Address - Fax:828-264-8612
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1982152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC093T4OtherBCBS
NC410034018OtherRRMC
NC5901497Medicaid
NC0853510001OtherCIGNA GOVERNMENT SERVICES MEDICARE PART B DME
NC2473819Medicare PIN
NC410034018OtherRRMC
NC5901497Medicaid