Provider Demographics
NPI:1548681786
Name:AMY LANE APRN, L.L.C.
Entity type:Organization
Organization Name:AMY LANE APRN, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:860-823-0245
Mailing Address - Street 1:410 SALEM TPKE
Mailing Address - Street 2:
Mailing Address - City:BOZRAH
Mailing Address - State:CT
Mailing Address - Zip Code:06334-1519
Mailing Address - Country:US
Mailing Address - Phone:860-823-0245
Mailing Address - Fax:860-213-8350
Practice Address - Street 1:410 SALEM TPKE
Practice Address - Street 2:
Practice Address - City:BOZRAH
Practice Address - State:CT
Practice Address - Zip Code:06334-1519
Practice Address - Country:US
Practice Address - Phone:860-823-0245
Practice Address - Fax:860-213-8350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-13
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002158261QM0850X, 261QM0855X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236346Medicaid
CT500000779Medicare Oscar/Certification
CT004236346Medicaid