Healthcare Provider Details

I. General information

NPI: 1134545759
Provider Name (Legal Business Name): SHANELL H VANCE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2014
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

198 CHARLTON RD
STURBRIDGE MA
01566
US

IV. Provider business mailing address

PO BOX 40
SOUTHBRIDGE MA
01550-0040
US

V. Phone/Fax

Practice location:
  • Phone: 508-347-9240
  • Fax: 508-347-5361
Mailing address:
  • Phone: 508-909-7799
  • Fax: 508-764-2432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2289391
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2289391
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: