Provider Demographics
NPI:1083303481
Name:VINSON, MARY GRACE EVASCO (FNP)
Entity Type:Individual
Prefix:MS
First Name:MARY GRACE
Middle Name:EVASCO
Last Name:VINSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5388 MONTERREY RD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-7015
Mailing Address - Country:US
Mailing Address - Phone:850-758-0765
Mailing Address - Fax:
Practice Address - Street 1:5388 MONTERREY RD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-7015
Practice Address - Country:US
Practice Address - Phone:850-758-0765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-02
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11026114363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner