Provider Demographics
NPI:1134545759
Name:VANCE, SHANELL H (NP)
Entity type:Individual
Prefix:
First Name:SHANELL
Middle Name:H
Last Name:VANCE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-0040
Mailing Address - Country:US
Mailing Address - Phone:508-909-7799
Mailing Address - Fax:508-764-2432
Practice Address - Street 1:198 CHARLTON RD
Practice Address - Street 2:
Practice Address - City:STURBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01566
Practice Address - Country:US
Practice Address - Phone:508-347-9240
Practice Address - Fax:508-347-5361
Is Sole Proprietor?:No
Enumeration Date:2014-03-06
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2289391163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse