Provider Demographics
NPI:1306493713
Name:HANCOCK, VANESSA LYNN (PTA)
Entity type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:LYNN
Last Name:HANCOCK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-4377
Mailing Address - Country:US
Mailing Address - Phone:843-742-9611
Mailing Address - Fax:
Practice Address - Street 1:120 LAKES AT LITCHFIELD DR
Practice Address - Street 2:
Practice Address - City:PAWLEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585-9001
Practice Address - Country:US
Practice Address - Phone:843-235-9393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2907225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant