Provider Demographics
NPI:1639599277
Name:VITALE, ERIN GARDNER (RN, BSN)
Entity Type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:GARDNER
Last Name:VITALE
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:MS
Other - First Name:ERIN
Other - Middle Name:MICHELLE
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, BSN
Mailing Address - Street 1:1 WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2722
Mailing Address - Country:US
Mailing Address - Phone:937-208-8394
Mailing Address - Fax:
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-395-6665
Practice Address - Fax:937-395-6668
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN356439363LA2100X
OHAPRN.CNP.16273363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0107049Medicaid