Provider Demographics
NPI:1508090903
Name:VINCENT, TINA THIBAULT (NP)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:THIBAULT
Last Name:VINCENT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:THIBAULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:4757 NETHERSTONE CT NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-6908
Mailing Address - Country:US
Mailing Address - Phone:678-494-8939
Mailing Address - Fax:678-264-2236
Practice Address - Street 1:4757 NETHERSTONE CT NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-6908
Practice Address - Country:US
Practice Address - Phone:678-494-8939
Practice Address - Fax:678-264-2236
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN163999 NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily