Provider Demographics
NPI:1871516351
Name:LAIN, JEANETTE L (PA)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:L
Last Name:LAIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12109 COUNTY ROAD 103
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:FL
Mailing Address - Zip Code:34484-2951
Mailing Address - Country:US
Mailing Address - Phone:352-205-8981
Mailing Address - Fax:
Practice Address - Street 1:685 PEACHWOOD DR
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-0804
Practice Address - Country:US
Practice Address - Phone:386-736-3463
Practice Address - Fax:386-736-3492
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104131363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKQ64004Medicare UPIN
OK900522127Medicare ID - Type Unspecified