Provider Demographics
NPI:1851750830
Name:VINCENT, STACY LYNN
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LYNN
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 1:4232 29TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-1936
Mailing Address - Country:US
Mailing Address - Phone:616-942-1818
Mailing Address - Fax:616-942-6567
Practice Address - Street 1:4232 29TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-1936
Practice Address - Country:US
Practice Address - Phone:616-942-1818
Practice Address - Fax:616-942-6567
Is Sole Proprietor?:No
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3501003278237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3501003278OtherSTATE OF MICHIGAN LICENSE