Provider Demographics
NPI:1891423349
Name:VANCE, STACEY (PRSS)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:VANCE
Suffix:
Gender:
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 KANAWHA TER APT D
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:WV
Mailing Address - Zip Code:25177-2942
Mailing Address - Country:US
Mailing Address - Phone:304-373-6956
Mailing Address - Fax:
Practice Address - Street 1:2333 MACCORKLE AVE
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177-2073
Practice Address - Country:US
Practice Address - Phone:304-766-0060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-11
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22-978175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist