1063479723 NPI number — DR. SHERYLL ANGELA VINCENT MD

Table of content: DR. SHERYLL ANGELA VINCENT MD (NPI 1063479723)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063479723 NPI number — DR. SHERYLL ANGELA VINCENT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VINCENT
Provider First Name:
SHERYLL
Provider Middle Name:
ANGELA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FLETCHER-VINCENT
Provider Other First Name:
SHERYLL
Provider Other Middle Name:
ANGELA
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1063479723
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5440 WATKINS DR
Provider Second Line Business Mailing Address:
STE A
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39206-2034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-981-3636
Provider Business Mailing Address Fax Number:
601-982-5335

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5440 WATKINS DR
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39206-2034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-981-3636
Provider Business Practice Location Address Fax Number:
601-982-5335
Provider Enumeration Date:
04/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X , with the licence number:  14014 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00116035 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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