Provider Demographics
NPI:1730614207
Name:LANE, JAIMIE (MS)
Entity type:Individual
Prefix:
First Name:JAIMIE
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:JAIMIE
Other - Middle Name:
Other - Last Name:OTTONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:51 KING AVE
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-2343
Mailing Address - Country:US
Mailing Address - Phone:631-553-0667
Mailing Address - Fax:
Practice Address - Street 1:51 KING AVE
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-2343
Practice Address - Country:US
Practice Address - Phone:631-553-0667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-21
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist