Provider Demographics
NPI:1669647046
Name:VANCE, ANGELA ROSE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:ROSE
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 1:312 DIAMOND AVE
Mailing Address - Street 2:
Mailing Address - City:BELLE
Mailing Address - State:WV
Mailing Address - Zip Code:25015-1303
Mailing Address - Country:US
Mailing Address - Phone:304-949-3443
Mailing Address - Fax:
Practice Address - Street 1:312 DIAMOND AVE
Practice Address - Street 2:
Practice Address - City:BELLE
Practice Address - State:WV
Practice Address - Zip Code:25015-1303
Practice Address - Country:US
Practice Address - Phone:304-949-3443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2007-2294225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist