Healthcare Provider Details

I. General information

NPI: 1295107357
Provider Name (Legal Business Name): TAMMY VINCENT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2015
Last Update Date: 10/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14116 CUSTOMS BLVD
GULFPORT MS
39503-5164
US

IV. Provider business mailing address

422 MEMORIAL BLVD
PICAYUNE MS
39466-5544
US

V. Phone/Fax

Practice location:
  • Phone: 601-957-6300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR872175
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: