Provider Demographics
NPI:1679022933
Name:VANCE, DESIREE
Entity type:Individual
Prefix:
First Name:DESIREE
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 1:3170 KETTERING BLVD BLDG B3
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:
Practice Address - Street 1:9000 N MAIN ST STE 300
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45415-1165
Practice Address - Country:US
Practice Address - Phone:937-832-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-28
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.019953363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0189735Medicaid