Provider Demographics
NPI:1407885148
Name:VANCE, MARY E (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:VANCE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8735 KINGSPORT HWY
Mailing Address - Street 2:
Mailing Address - City:CHUCKEY
Mailing Address - State:TN
Mailing Address - Zip Code:37641-6908
Mailing Address - Country:US
Mailing Address - Phone:423-329-4610
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN ROAD EAST
Practice Address - Street 2:MAIL ROUTE NM
Practice Address - City:008-B213
Practice Address - State:MN
Practice Address - Zip Code:55343
Practice Address - Country:US
Practice Address - Phone:423-388-1730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2020-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN007047363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN100025524OtherPHP
TN3343736Medicaid
TN4117453OtherBLUECROSSBLUESHIELD
TNTN01N4OtherJOHN DEERE
TN4117453OtherBLUECROSSBLUESHIELD
TN3343736Medicaid
3343736Medicare Oscar/Certification