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General NPI Number Information
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NPI Number | 1477198018
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Entity Type | Individual
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Provider Name | TERESA RENA WILES VANCE LMT
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Gender | Female
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Dates
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Enumeration Date | 11/07/2019
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Last Update Date | 11/07/2019
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Provider Practice Location Address
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Address Line | 659 AUBURN AVE NE STE G18
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City | ATLANTA
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State | GA
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Zip | 30312-1977
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Country | US
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Telephone | 470-322-5619
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Fax |
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Provider Business Mailing Address
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Address Line | 1578 VAN VLECK AVE SE
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City | ATLANTA
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State | GA
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Zip | 30316-2150
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Country | US
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Telephone | 703-473-7338
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MT010261
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License Number State | GA
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