Provider Demographics
NPI:1043784341
Name:VITOULIS, MICHELLE LYNN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LYNN
Last Name:VITOULIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LYNN
Other - Last Name:LANDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:1999 ROUTE 67
Mailing Address - Street 2:
Mailing Address - City:LEEDS
Mailing Address - State:NY
Mailing Address - Zip Code:12451-1133
Mailing Address - Country:US
Mailing Address - Phone:518-929-7824
Mailing Address - Fax:
Practice Address - Street 1:1999 ROUTE 67
Practice Address - Street 2:
Practice Address - City:LEEDS
Practice Address - State:NY
Practice Address - Zip Code:12451-1133
Practice Address - Country:US
Practice Address - Phone:518-929-7824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-20
Last Update Date:2019-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226682-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse