Healthcare Provider Details

I. General information

NPI: 1831926286
Provider Name (Legal Business Name): MISTY ELIZABETH VICENTE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 E BARNETT RD
MEDFORD OR
97504-8219
US

IV. Provider business mailing address

1333 E BARNETT RD
MEDFORD OR
97504-8219
US

V. Phone/Fax

Practice location:
  • Phone: 541-779-4711
  • Fax:
Mailing address:
  • Phone: 541-779-4711
  • Fax: 541-779-0796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10032608
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: