Healthcare Provider Details

I. General information

NPI: 1417133083
Provider Name (Legal Business Name): MICHELLE VINCHWATER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 CHADWICK DR SUITE 150A
JACKSON MS
39204-3463
US

IV. Provider business mailing address

1860 CHADWICK DR SUITE 150A
JACKSON MS
39204-3463
US

V. Phone/Fax

Practice location:
  • Phone: 601-376-2818
  • Fax: 601-376-2831
Mailing address:
  • Phone: 601-376-2818
  • Fax: 601-376-2831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR860390
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: