Healthcare Provider Details

I. General information

NPI: 1962924530
Provider Name (Legal Business Name): NICOLE VINCENT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2017
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 LAKESHORE PKWY
ROCK HILL SC
29730-4205
US

IV. Provider business mailing address

455 LAKESHORE PKWY
ROCK HILL SC
29730-4205
US

V. Phone/Fax

Practice location:
  • Phone: 803-909-6363
  • Fax: 803-909-6390
Mailing address:
  • Phone: 803-909-6363
  • Fax: 803-909-6390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberARNP9294061
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberARNP9294061
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number25653
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: