Provider Demographics
NPI:1447888706
Name:VANCE, CAMERON S
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:S
Last Name:VANCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:537 BELLWOOD DR APT 1
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2336
Mailing Address - Country:US
Mailing Address - Phone:270-312-2500
Mailing Address - Fax:
Practice Address - Street 1:537 BELLWOOD DR APT 1
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2336
Practice Address - Country:US
Practice Address - Phone:270-312-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-31
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1179636175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist