Provider Demographics
NPI:1174751093
Name:VANCE, LINDA M (CFNP)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:M
Last Name:VANCE
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 CHADWICK DR STE 104
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-3465
Mailing Address - Country:US
Mailing Address - Phone:601-566-1644
Mailing Address - Fax:601-566-1644
Practice Address - Street 1:1860 CHADWICK DR STE 104
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3465
Practice Address - Country:US
Practice Address - Phone:601-566-1644
Practice Address - Fax:601-566-1644
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR718637363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01039029Medicaid