Provider Demographics
NPI:1588690689
Name:VANCE, PENNY D (FNP-BC)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:D
Last Name:VANCE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 KATHERINE DR STE A
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9588
Mailing Address - Country:US
Mailing Address - Phone:601-665-4162
Mailing Address - Fax:855-830-3484
Practice Address - Street 1:215 KATHERINE DR STE A
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9588
Practice Address - Country:US
Practice Address - Phone:601-665-4162
Practice Address - Fax:855-830-3484
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS652334363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS005238298Medicaid
MSP01629801OtherRAILROAD MEDICARE
MSP01629801OtherRAILROAD MEDICARE
MS05238298Medicaid