Provider Demographics
NPI:1003390980
Name:VANCE, PHYLLIS (APRN)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:VANCE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:
Other - Last Name:FAULKNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10748 VIRGINIA PLZ, SUITE 107
Mailing Address - Street 2:
Mailing Address - City:LAVISTA
Mailing Address - State:NE
Mailing Address - Zip Code:68128-3265
Mailing Address - Country:US
Mailing Address - Phone:402-933-4411
Mailing Address - Fax:888-507-5931
Practice Address - Street 1:10748 VIRGINIA PLZ, SUITE 107
Practice Address - Street 2:
Practice Address - City:LAVISTA
Practice Address - State:NE
Practice Address - Zip Code:68128-3265
Practice Address - Country:US
Practice Address - Phone:402-933-4411
Practice Address - Fax:888-507-5931
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012687363LP0808X
NE113743363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health