Provider Demographics
NPI:1407560147
Name:VITAL, JEAN ALMANOR
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:ALMANOR
Last Name:VITAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-1422
Mailing Address - Country:US
Mailing Address - Phone:617-599-8819
Mailing Address - Fax:
Practice Address - Street 1:212 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-1422
Practice Address - Country:US
Practice Address - Phone:617-599-8819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA236407363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner