Provider Demographics
NPI:1801372693
Name:VANCE, MARION RENEE
Entity Type:Individual
Prefix:
First Name:MARION
Middle Name:RENEE
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 1:848 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4905
Mailing Address - Country:US
Mailing Address - Phone:662-844-4177
Mailing Address - Fax:662-844-3877
Practice Address - Street 1:848 S MADISON ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4905
Practice Address - Country:US
Practice Address - Phone:662-844-4177
Practice Address - Fax:662-844-3877
Is Sole Proprietor?:No
Enumeration Date:2018-07-14
Last Update Date:2018-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902398363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily