Provider Demographics
NPI:1972093888
Name:LANE, MARINA (MS RD CLC)
Entity type:Individual
Prefix:MRS
First Name:MARINA
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:MS RD CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N GOULD ST STE N
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-6317
Mailing Address - Country:US
Mailing Address - Phone:720-680-2940
Mailing Address - Fax:
Practice Address - Street 1:30 N GOULD ST STE N
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-6317
Practice Address - Country:US
Practice Address - Phone:720-680-2940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009597133N00000X, 133V00000X
282242174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No174N00000XOther Service ProvidersLactation Consultant, Non-RN