Healthcare Provider Details

I. General information

NPI: 1376544874
Provider Name (Legal Business Name): PAMELA L VINCENT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 W LINCOLN AVE
ANAHEIM CA
92805-2927
US

IV. Provider business mailing address

3214 N UNIVERSITY AVE # 224
PROVO UT
84604-4405
US

V. Phone/Fax

Practice location:
  • Phone: 714-527-6561
  • Fax:
Mailing address:
  • Phone: 801-885-2303
  • Fax: 801-437-3273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number188338-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number29118-20
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number29118-20
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberG145852
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: