Provider Demographics
NPI:1255359717
Name:VINCENT, CARROLL LOGAN (APN ,PMHNP- BC)
Entity type:Individual
Prefix:MS
First Name:CARROLL
Middle Name:LOGAN
Last Name:VINCENT
Suffix:
Gender:F
Credentials:APN ,PMHNP- BC
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Mailing Address - Street 1:1997 HIGHWAY 51 S
Mailing Address - Street 2:PROFESSIONAL CARE SERVICES OF WEST TN, INC.
Mailing Address - City:COVINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38019-3630
Mailing Address - Country:US
Mailing Address - Phone:901-476-8967
Mailing Address - Fax:901-313-1125
Practice Address - Street 1:1997 HIGHWAY 51 S
Practice Address - Street 2:PROFESSIONAL CARE SERVICES OF WEST TN, INC.
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019-3630
Practice Address - Country:US
Practice Address - Phone:901-476-8967
Practice Address - Fax:901-313-1125
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNAPN0000007369363LP0808X
NE111003363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MV0888694OtherDEA
MV0888694OtherDEA