Provider Demographics
NPI:1245674084
Name:VANCE, KALEY DIANE
Entity type:Individual
Prefix:
First Name:KALEY
Middle Name:DIANE
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:PO BOX 452
Mailing Address - Street 2:
Mailing Address - City:PECKS MILL
Mailing Address - State:WV
Mailing Address - Zip Code:25547-0452
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:206 HUFF CREEK HIGHWAY
Practice Address - Street 2:
Practice Address - City:MAN
Practice Address - State:WV
Practice Address - Zip Code:25635-3331
Practice Address - Country:US
Practice Address - Phone:304-583-2404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-23
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0008582183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist