Provider Demographics
NPI:1114686763
Name:VITALE, LISA ANN (DC)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:VITALE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 FOREST HILL RD STE C1
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6314
Mailing Address - Country:US
Mailing Address - Phone:718-987-2273
Mailing Address - Fax:718-987-2277
Practice Address - Street 1:1235 FOREST HILL RD STE C1
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6314
Practice Address - Country:US
Practice Address - Phone:718-987-2273
Practice Address - Fax:718-987-2277
Is Sole Proprietor?:No
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013542111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor