Provider Demographics
NPI:1083090955
Name:VINCENT, SANDY ANNETTE (LPNCEO)
Entity Type:Individual
Prefix:
First Name:SANDY
Middle Name:ANNETTE
Last Name:VINCENT
Suffix:
Gender:F
Credentials:LPNCEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 WASHINGTON ST STE 410
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-3530
Mailing Address - Country:US
Mailing Address - Phone:757-337-0766
Mailing Address - Fax:757-966-2197
Practice Address - Street 1:505 WASHINGTON ST STE 410
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-3530
Practice Address - Country:US
Practice Address - Phone:757-337-0766
Practice Address - Fax:757-966-2197
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAHCO16855251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0157253466Medicaid
VA0160576655Medicaid