Provider Demographics
NPI:1568218378
Name:VANCE, DETRA L
Entity Type:Individual
Prefix:MS
First Name:DETRA
Middle Name:L
Last Name:VANCE
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 1:1729 E CALDWELL ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-8044
Mailing Address - Country:US
Mailing Address - Phone:602-348-8278
Mailing Address - Fax:
Practice Address - Street 1:1729 E CALDWELL ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-8044
Practice Address - Country:US
Practice Address - Phone:602-348-8278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ999950215251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care