Provider Demographics
NPI:1477697498
Name:PANKEY, VIVECA MELODY (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:VIVECA
Middle Name:MELODY
Last Name:PANKEY
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MS
Other - First Name:VIVECA
Other - Middle Name:MELODY
Other - Last Name:FRYE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:1719 EMPRESS LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4747
Mailing Address - Country:US
Mailing Address - Phone:910-551-4960
Mailing Address - Fax:
Practice Address - Street 1:1719 EMPRESS LN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4747
Practice Address - Country:US
Practice Address - Phone:910-551-4960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3393235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412154Medicaid