Provider Demographics
NPI:1063479723
Name:VINCENT, SHERYLL ANGELA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHERYLL
Middle Name:ANGELA
Last Name:VINCENT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHERYLL
Other - Middle Name:ANGELA
Other - Last Name:FLETCHER-VINCENT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5440 WATKINS DR
Mailing Address - Street 2:STE A
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-2034
Mailing Address - Country:US
Mailing Address - Phone:601-981-3636
Mailing Address - Fax:601-982-5335
Practice Address - Street 1:5440 WATKINS DR
Practice Address - Street 2:STE A
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-2034
Practice Address - Country:US
Practice Address - Phone:601-981-3636
Practice Address - Fax:601-982-5335
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14014207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116035Medicaid
MS370000387Medicare PIN
MS00116035Medicaid