Provider Demographics
NPI:1104416007
Name:VANCE, OGHENETEGA EWEFADA (FNP)
Entity type:Individual
Prefix:
First Name:OGHENETEGA
Middle Name:EWEFADA
Last Name:VANCE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:OGHENETEGA
Other - Middle Name:EGURIASE
Other - Last Name:EWEFADA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5825 E CALLE GUADALUPE
Mailing Address - Street 2:
Mailing Address - City:GUADALUPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-2664
Mailing Address - Country:US
Mailing Address - Phone:480-344-6000
Mailing Address - Fax:
Practice Address - Street 1:5825 E CALLE GUADALUPE
Practice Address - Street 2:
Practice Address - City:GUADALUPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-2664
Practice Address - Country:US
Practice Address - Phone:833-855-9973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2150369163W00000X
MNF07210101363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse