Healthcare Provider Details

I. General information

NPI: 1457161663
Provider Name (Legal Business Name): BEATRICE HOME VINCENT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2025
Last Update Date: 01/20/2025
Certification Date: 01/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 FOXON RD
EAST HAVEN CT
06513-2038
US

IV. Provider business mailing address

283 MOUNT FAIR DR
WATERTOWN CT
06795-1657
US

V. Phone/Fax

Practice location:
  • Phone: 475-441-7809
  • Fax:
Mailing address:
  • Phone: 203-224-9376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14017
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number14017
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number14017
License Number StateCT
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number14017
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: