Provider Demographics
NPI:1225712102
Name:VANCE, AVERY JEAN (RDN, LDN)
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:JEAN
Last Name:VANCE
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 MICHAEL ST
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-5522
Mailing Address - Country:US
Mailing Address - Phone:870-476-4905
Mailing Address - Fax:
Practice Address - Street 1:2420 LINWOOD DR # 3
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-6122
Practice Address - Country:US
Practice Address - Phone:870-236-9756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1983133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered