Provider Demographics
NPI:1104497312
Name:VINCENT, PORTIA (C-FNP)
Entity type:Individual
Prefix:
First Name:PORTIA
Middle Name:
Last Name:VINCENT
Suffix:
Gender:F
Credentials:C-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 WALNUT GLEN DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-7580
Mailing Address - Country:US
Mailing Address - Phone:397-944-3385
Mailing Address - Fax:
Practice Address - Street 1:2845 PROGRESS WAY
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-7704
Practice Address - Country:US
Practice Address - Phone:937-944-3385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0029202363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily