Basic Information
| Provider Information | |||||||||
| NPI: | 1245626712 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LANE | ||||||||
| FirstName: | KYRSTIN | ||||||||
| MiddleName: | LYNNICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455631 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 700 W 7TH ST STE S-270D | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900173768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2139888380 | ||||||||
| FaxNumber: | 2139888390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2015 | ||||||||
| LastUpdateDate: | 10/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | A155305 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | FL8015908 | 01 | CA | DEA | OTHER | A155305 | 01 | CA | STATE LICENSE | OTHER |