Provider Demographics
NPI:1760245716
Name:LANE, PATRICIA BRIDGET (RDN, LD/N, LD)
Entity type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:BRIDGET
Last Name:LANE
Suffix:
Gender:F
Credentials:RDN, LD/N, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 SE GASLIGHT ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7332
Mailing Address - Country:US
Mailing Address - Phone:954-592-2502
Mailing Address - Fax:
Practice Address - Street 1:2225 SE GASLIGHT ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7332
Practice Address - Country:US
Practice Address - Phone:954-592-2502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-02
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND10141133V00000X
NMLD-2023-048133V00000X
TXDT86915133VN1201X
86015440133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management