Healthcare Provider Details

I. General information

NPI: 1861310617
Provider Name (Legal Business Name): STACY RENEE VANCE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 STEVE DR
RUSSELL SPRINGS KY
42642-4622
US

IV. Provider business mailing address

PO BOX 1080
BURKESVILLE KY
42717-1080
US

V. Phone/Fax

Practice location:
  • Phone: 270-866-3161
  • Fax: 270-866-3163
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4059635
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: