Healthcare Provider Details

I. General information

NPI: 1063892453
Provider Name (Legal Business Name): LETATIA VANCE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2015
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2533 BERT KOUNS INDUSTRIAL LOOP
SHREVEPORT LA
71118-3158
US

IV. Provider business mailing address

2533 BERT KOUNS INDUSTRIAL LOOP STE 106
SHREVEPORT LA
71118-3158
US

V. Phone/Fax

Practice location:
  • Phone: 318-686-3770
  • Fax: 318-686-3838
Mailing address:
  • Phone: 318-686-3770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberA10561
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: