Provider Demographics
NPI:1710589643
Name:PROVANCE, MARIANNE
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:PROVANCE
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 1:983 HOMESTEAD AVE
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-1131
Mailing Address - Country:US
Mailing Address - Phone:330-265-9241
Mailing Address - Fax:
Practice Address - Street 1:983 HOMESTEAD AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-1131
Practice Address - Country:US
Practice Address - Phone:330-265-9241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172A00000X
OH172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7611029Medicaid