Provider Demographics
NPI:1114366002
Name:VITALE, ELIZABETH M (RDN, CDCES)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:M
Last Name:VITALE
Suffix:
Gender:F
Credentials:RDN, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3939 VESELICH AVE APT 302
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039-1485
Mailing Address - Country:US
Mailing Address - Phone:808-595-6237
Mailing Address - Fax:
Practice Address - Street 1:3939 VESELICH AVE APT 302
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90039-1485
Practice Address - Country:US
Practice Address - Phone:808-595-6237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
CA1031643133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered