Provider Demographics
NPI:1417251653
Name:NANCE, CASSAUNDRA LYNETTE
Entity Type:Individual
Prefix:
First Name:CASSAUNDRA
Middle Name:LYNETTE
Last Name:NANCE
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 1:703 WILLIAMS AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-4225
Mailing Address - Country:US
Mailing Address - Phone:850-319-5693
Mailing Address - Fax:850-785-5928
Practice Address - Street 1:703 WILLIAMS AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-4225
Practice Address - Country:US
Practice Address - Phone:850-319-5693
Practice Address - Fax:850-785-5928
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL683319596Medicaid
FL683319501Medicaid