Provider Demographics
NPI:1861877078
Name:VANCE, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:VANCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:MC DOWELL
Mailing Address - State:KY
Mailing Address - Zip Code:41647-0247
Mailing Address - Country:US
Mailing Address - Phone:606-377-3431
Mailing Address - Fax:606-377-3489
Practice Address - Street 1:9879 KY ROUTE 122
Practice Address - Street 2:
Practice Address - City:MC DOWELL
Practice Address - State:KY
Practice Address - Zip Code:41647-6026
Practice Address - Country:US
Practice Address - Phone:606-377-3431
Practice Address - Fax:606-377-3489
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA02777225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant