Provider Demographics
NPI:1003843616
Name:PENN, VANCE V (MED, ATC, CSCS)
Entity Type:Individual
Prefix:MR
First Name:VANCE
Middle Name:V
Last Name:PENN
Suffix:
Gender:M
Credentials:MED, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CMR 431 BOX 2152
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09175
Mailing Address - Country:US
Mailing Address - Phone:491609-396-8204
Mailing Address - Fax:
Practice Address - Street 1:CMR 431 BOX 2152
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09175
Practice Address - Country:US
Practice Address - Phone:491609-396-8204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer