MEDICARE: ANGELIQUE VINCENT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician
2	3747A0650X	Attendant Care Provider

General Provider Information

NPI Number	:	1972154425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELIQUE VINCENT

Provider Business Mailing Address
First Line	:	4510 SALT LAKE BLVD STE C4
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96818-3171
Country	:	US
Telephone Number	:	253-881-9945
Fax Number	:

Provider Business Practice Location Address
First Line	:	4510 SALT LAKE BLVD STE C4
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96818-3171
Country	:	US
Telephone Number	:	808-486-1804
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2019
Last Update Date	:	01/31/2022

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Directions to “ ANGELIQUE VINCENT ” Practice Location

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