Provider Demographics
NPI:1861831869
Name:VANCE, KATIE E (PA)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:E
Last Name:VANCE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1123 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:TN
Mailing Address - Zip Code:38330-1019
Mailing Address - Country:US
Mailing Address - Phone:731-692-2853
Mailing Address - Fax:731-692-2367
Practice Address - Street 1:1123 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:TN
Practice Address - Zip Code:38330-1019
Practice Address - Country:US
Practice Address - Phone:731-692-2853
Practice Address - Fax:731-692-2367
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-24
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2351363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant