Provider Demographics
NPI:1417012022
Name:VANCE, CAROL KLETT (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:KLETT
Last Name:VANCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 CURLEW DR STE 6
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-4719
Mailing Address - Country:US
Mailing Address - Phone:208-523-4688
Mailing Address - Fax:208-523-4990
Practice Address - Street 1:1619 CURLEW DR STE 6
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-4719
Practice Address - Country:US
Practice Address - Phone:208-523-4688
Practice Address - Fax:208-523-4990
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM97512080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010158422OtherREGENCE BLUESHIELD
IDB6254OtherBCBS