Provider Demographics
NPI:1538473194
Name:VANNAH, COURTNEY ELAINE (IPDH, MS)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:ELAINE
Last Name:VANNAH
Suffix:
Gender:F
Credentials:IPDH, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2656
Mailing Address - Country:US
Mailing Address - Phone:207-221-4249
Mailing Address - Fax:207-221-7889
Practice Address - Street 1:716 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2656
Practice Address - Country:US
Practice Address - Phone:207-221-4249
Practice Address - Fax:207-221-7889
Is Sole Proprietor?:No
Enumeration Date:2010-08-05
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEIPDH32124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist