Provider Demographics
NPI:1346265717
Name:VINCENZ, MARY SEKAN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SEKAN
Last Name:VINCENZ
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 1:127 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85701-2005
Mailing Address - Country:US
Mailing Address - Phone:520-327-4505
Mailing Address - Fax:520-202-1889
Practice Address - Street 1:1671 W GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-1433
Practice Address - Country:US
Practice Address - Phone:520-327-4505
Practice Address - Fax:520-202-1889
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN025331363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ805517Medicare ID - Type UnspecifiedAHCCCS NUMBER