Provider Demographics
NPI:1003063884
Name:VINCENT, MIRANDA R (APRN)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:R
Last Name:VINCENT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:R
Other - Last Name:GREENFELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:459 ROMANOCK ROAD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825
Mailing Address - Country:US
Mailing Address - Phone:203-292-3631
Mailing Address - Fax:
Practice Address - Street 1:15 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-1351
Practice Address - Country:US
Practice Address - Phone:203-452-8322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-22
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002406363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics