Healthcare Provider Details

I. General information

NPI: 1902546203
Provider Name (Legal Business Name): DERRIC JAMES VIGEANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 05/09/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 CHALKSTONE AVE
PROVIDENCE RI
02908-4728
US

IV. Provider business mailing address

646 GREENVILLE AVE
JOHNSTON RI
02919-1331
US

V. Phone/Fax

Practice location:
  • Phone: 401-456-2000
  • Fax:
Mailing address:
  • Phone: 401-426-9887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberPA1450
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code364SP0810X
TaxonomyChild & Family Psychiatric/Mental Health Clinical Nurse Specialist
License NumberPA01450
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: