Healthcare Provider Details

I. General information

NPI: 1659831428
Provider Name (Legal Business Name): HALEY RENEE VANCE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 03/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 E MAIN ST
SENATOBIA MS
38668-2140
US

IV. Provider business mailing address

214 E MAIN ST
SENATOBIA MS
38668-2140
US

V. Phone/Fax

Practice location:
  • Phone: 662-560-0602
  • Fax:
Mailing address:
  • Phone: 662-560-0602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0862
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: