Provider Demographics
NPI:1184231615
Name:VANCE, KELLY
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:VANCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 CORDELIA ST
Mailing Address - Street 2:
Mailing Address - City:CEDAR BLUFF
Mailing Address - State:VA
Mailing Address - Zip Code:24609-9592
Mailing Address - Country:US
Mailing Address - Phone:276-971-3218
Mailing Address - Fax:
Practice Address - Street 1:1951 2ND ST
Practice Address - Street 2:
Practice Address - City:RICHLANDS
Practice Address - State:VA
Practice Address - Zip Code:24641-2303
Practice Address - Country:US
Practice Address - Phone:276-963-0284
Practice Address - Fax:276-963-4465
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202208454183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist