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General NPI Number Information
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NPI Number | 1508090903
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Entity Type | Individual
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Provider Name | TINA THIBAULT VINCENT N.P.
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Gender | Female
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Dates
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Enumeration Date | 05/13/2009
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Last Update Date | 05/13/2009
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Provider Practice Location Address
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Address Line | 4757 NETHERSTONE CT NE
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City | MARIETTA
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State | GA
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Zip | 30066-6908
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Country | US
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Telephone | 678-494-8939
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Fax | 678-264-2236
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Provider Business Mailing Address
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Address Line | 4757 NETHERSTONE CT NE
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City | MARIETTA
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State | GA
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Zip | 30066-6908
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Country | US
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Telephone | 678-494-8939
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Fax | 678-264-2236
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | RN163999 NP
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License Number State | GA
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