Provider Demographics
NPI:1538476072
Name:VITAL, MANUELA (A-NP)
Entity Type:Individual
Prefix:
First Name:MANUELA
Middle Name:
Last Name:VITAL
Suffix:
Gender:F
Credentials:A-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6859 E. REMBRANDT AVE
Mailing Address - Street 2:SUITE 117
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-3630
Mailing Address - Country:US
Mailing Address - Phone:480-632-1577
Mailing Address - Fax:480-632-1574
Practice Address - Street 1:6859 E. REMBRANDT AVE
Practice Address - Street 2:SUITE 117
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212-3630
Practice Address - Country:US
Practice Address - Phone:480-632-1577
Practice Address - Fax:480-632-1574
Is Sole Proprietor?:No
Enumeration Date:2010-09-03
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3706363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health