Basic Information
| Provider Information | |||||||||
| NPI: | 1003424748 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANCE | ||||||||
| FirstName: | MALLORY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MOT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8205 PRESIDENTS DR | ||||||||
| Address2: | |||||||||
| City: | HUMMELSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170368621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178392188 | ||||||||
| FaxNumber: | 7175651104 | ||||||||
| Practice Location | |||||||||
| Address1: | 960 COMMONWEALTH BLVD | ||||||||
| Address2: | |||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388049762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622603789 | ||||||||
| FaxNumber: | 6622603790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2020 | ||||||||
| LastUpdateDate: | 07/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | PT3794 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.