Provider Demographics
NPI:1295613420
Name:BOOM, VINCENT (RN, PHD)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:BOOM
Suffix:
Gender:M
Credentials:RN, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 ARBOR LAWN DR
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-4062
Mailing Address - Country:US
Mailing Address - Phone:817-727-5558
Mailing Address - Fax:
Practice Address - Street 1:428 ARBOR LAWN DR
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-4062
Practice Address - Country:US
Practice Address - Phone:817-727-5558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-25
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA143410163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse