Provider Demographics
NPI:1639630171
Name:NANCE, MICHELLE RENEA
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEA
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 1:58945 BUSINESS CENTER DR
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-7307
Mailing Address - Country:US
Mailing Address - Phone:760-228-9657
Mailing Address - Fax:760-365-2072
Practice Address - Street 1:58945 BUSINESS CENTER DR
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-7307
Practice Address - Country:US
Practice Address - Phone:760-369-1074
Practice Address - Fax:760-365-2072
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-27
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1881788503Medicaid