Provider Demographics
NPI:1952300790
Name:VANCE, STACEY DROTT (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:DROTT
Last Name:VANCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37148-1218
Mailing Address - Country:US
Mailing Address - Phone:615-323-8873
Mailing Address - Fax:615-323-8874
Practice Address - Street 1:120 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-1218
Practice Address - Country:US
Practice Address - Phone:615-323-8873
Practice Address - Fax:615-323-8874
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD33966207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H20030Medicare UPIN