Provider Demographics
NPI:1417133083
Name:VINCHWATER, MICHELLE (NP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:VINCHWATER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 CHADWICK DR
Mailing Address - Street 2:SUITE 150A
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-3463
Mailing Address - Country:US
Mailing Address - Phone:601-376-2818
Mailing Address - Fax:601-376-2831
Practice Address - Street 1:1860 CHADWICK DR
Practice Address - Street 2:SUITE 150A
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3463
Practice Address - Country:US
Practice Address - Phone:601-376-2818
Practice Address - Fax:601-376-2831
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR860390363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01567538Medicaid
MS302I500392Medicare PIN