Healthcare Provider Details

I. General information

NPI: 1003390980
Provider Name (Legal Business Name): PHYLLIS VANCE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PHYLLIS FAULKNER

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 02/22/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10748 VIRGINIA PLZ, SUITE 107
LAVISTA NE
68128-3265
US

IV. Provider business mailing address

10748 VIRGINIA PLZ, SUITE 107
LAVISTA NE
68128-3265
US

V. Phone/Fax

Practice location:
  • Phone: 402-933-4411
  • Fax: 888-507-5931
Mailing address:
  • Phone: 402-933-4411
  • Fax: 888-507-5931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3012687
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number113743
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: