Provider Demographics
NPI:1326517020
Name:VINCENT, BETTY JUSTINE
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:JUSTINE
Last Name:VINCENT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 ALLSPICE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-9514
Mailing Address - Country:US
Mailing Address - Phone:407-558-4384
Mailing Address - Fax:
Practice Address - Street 1:2109 ALLSPICE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-9514
Practice Address - Country:US
Practice Address - Phone:407-558-4384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5231792164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL731640Medicaid