Provider Demographics
NPI:1164834347
Name:VANCE, CHARDONNAY (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARDONNAY
Middle Name:
Last Name:VANCE
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2290
Mailing Address - Street 2:
Mailing Address - City:WHITE SALMON
Mailing Address - State:WA
Mailing Address - Zip Code:98672-2290
Mailing Address - Country:US
Mailing Address - Phone:314-720-1644
Mailing Address - Fax:509-232-5809
Practice Address - Street 1:181 W JEWETT BLVD
Practice Address - Street 2:
Practice Address - City:WHITE SALMON
Practice Address - State:WA
Practice Address - Zip Code:98672-8974
Practice Address - Country:US
Practice Address - Phone:509-289-2119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-22
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PHYS-LIC-53568207Q00000X
ORMD181361207Q00000X, 207VX0000X
WAMD60734244207Q00000X
DEC1-0024847207Q00000X
TXT6799207Q00000X
MIEMC0000406207Q00000X
IDMC-0516207Q00000X
MS29232207Q00000X
NH21735207Q00000X
NV21239207Q00000X
SC88601207Q00000X
WV30684207Q00000X
WY11037A207Q00000X
OK38523207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2080300Medicaid