Provider Demographics
NPI:1508145756
Name:VITAL, TAVIA MARIE (RN, CDE)
Entity Type:Individual
Prefix:
First Name:TAVIA
Middle Name:MARIE
Last Name:VITAL
Suffix:
Gender:F
Credentials:RN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2560 24TH ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-5357
Mailing Address - Country:US
Mailing Address - Phone:309-788-0014
Mailing Address - Fax:309-793-3092
Practice Address - Street 1:2560 24TH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-5357
Practice Address - Country:US
Practice Address - Phone:309-788-0014
Practice Address - Fax:309-793-3092
Is Sole Proprietor?:No
Enumeration Date:2011-08-05
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041390337163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator