MEDICARE: MRS. STACY LYNN VINCENT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	237700000X	Hearing Instrument Specialist	3501003278	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3501003278	OTHER	MI	STATE OF MICHIGAN LICENSE

General Provider Information

NPI Number	:	1851750830
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STACY LYNN VINCENT

Provider Business Mailing Address
First Line	:	4232 29TH ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49512-1936
Country	:	US
Telephone Number	:	616-942-1818
Fax Number	:	616-942-6567

Provider Business Practice Location Address
First Line	:	4232 29TH ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49512-1936
Country	:	US
Telephone Number	:	616-942-1818
Fax Number	:	616-942-6567

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/18/2016
Last Update Date	:	02/18/2016

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