Provider Demographics
NPI:1346128261
Name:LANE, RAY ALLEN (NURSE PRACTIONER)
Entity type:Individual
Prefix:MR
First Name:RAY
Middle Name:ALLEN
Last Name:LANE
Suffix:
Gender:M
Credentials:NURSE PRACTIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 S GRAHAM RD
Mailing Address - Street 2:
Mailing Address - City:AVON PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33825-8155
Mailing Address - Country:US
Mailing Address - Phone:863-899-8905
Mailing Address - Fax:
Practice Address - Street 1:818 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-5642
Practice Address - Country:US
Practice Address - Phone:727-477-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-27
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11041872363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty