Provider Demographics
NPI:1336199363
Name:PENCE, VICKIE RENEE (MS,PA)
Entity Type:Individual
Prefix:MS
First Name:VICKIE
Middle Name:RENEE
Last Name:PENCE
Suffix:
Gender:F
Credentials:MS,PA
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 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:
Practice Address - Street 1:1101 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-0001
Practice Address - Country:US
Practice Address - Phone:573-882-1662
Practice Address - Fax:573-884-7318
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA965363A00000X
MO2010037370363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100509027Medicaid
NV100509027Medicaid
MO152360402Medicare PIN
103631Medicare PIN