Provider Demographics
NPI:1669957494
Name:RICHARDSON, NANCY VANCE (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:VANCE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 SEABROOK WAY
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-1745
Mailing Address - Country:US
Mailing Address - Phone:478-718-8239
Mailing Address - Fax:
Practice Address - Street 1:136 MARSHS EDGE LN
Practice Address - Street 2:
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-8898
Practice Address - Country:US
Practice Address - Phone:912-291-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA006603235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist