Provider Demographics
NPI:1629646476
Name:VINCENT, CANDICE LUCIANA
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:LUCIANA
Last Name:VINCENT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:LUCIANA
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4330 NW 173RD DR
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-3706
Mailing Address - Country:US
Mailing Address - Phone:305-790-8843
Mailing Address - Fax:
Practice Address - Street 1:4330 NW 173RD DR
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33055-3706
Practice Address - Country:US
Practice Address - Phone:305-790-8843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9467707163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse