Healthcare Provider Details

I. General information

NPI: 1104828045
Provider Name (Legal Business Name): LARRY ALLEN NANCE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 02/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7915 LAKE MANASSAS DRIVE SUTIE 205
GAINESVILLE NC
20155-3260
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 866-755-3551
  • Fax: 703-365-7702
Mailing address:
  • Phone: 866-775-3551
  • Fax: 703-365-7702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number0101037658
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101037658
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: