Provider Demographics
NPI:1558024984
Name:VITALE, GRETTELL V (MSN, RN, PHN)
Entity Type:Individual
Prefix:
First Name:GRETTELL
Middle Name:V
Last Name:VITALE
Suffix:
Gender:F
Credentials:MSN, RN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 E GONZALES RD STE 102
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93036-8293
Mailing Address - Country:US
Mailing Address - Phone:805-833-4581
Mailing Address - Fax:
Practice Address - Street 1:2220 E GONZALES RD STE 102
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-8293
Practice Address - Country:US
Practice Address - Phone:805-833-4581
Practice Address - Fax:805-981-5385
Is Sole Proprietor?:No
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA705149171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator