Provider Demographics
NPI:1700023389
Name:VANCE, MARLAINA B
Entity Type:Individual
Prefix:
First Name:MARLAINA
Middle Name:B
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 1:201 E HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-0206
Mailing Address - Country:US
Mailing Address - Phone:408-376-0900
Mailing Address - Fax:
Practice Address - Street 1:201 E HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-0206
Practice Address - Country:US
Practice Address - Phone:408-376-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-19
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT291608225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB104269Medicare PIN