Provider Demographics
NPI:1720349475
Name:VANCE, JAMIE LOUISE (DO)
Entity Type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:LOUISE
Last Name:VANCE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MS
Other - First Name:JAMIE
Other - Middle Name:LOUISE
Other - Last Name:DILLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1322 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-1322
Mailing Address - Country:US
Mailing Address - Phone:304-647-1139
Mailing Address - Fax:304-647-3006
Practice Address - Street 1:1322 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-1322
Practice Address - Country:US
Practice Address - Phone:304-647-1139
Practice Address - Fax:304-647-3006
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2022-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2754207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1720349475Medicaid