Provider Demographics
NPI:1679119523
Name:VITELLI, NICOLE EVE (MSED)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:EVE
Last Name:VITELLI
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 SARA CT
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12308-1074
Mailing Address - Country:US
Mailing Address - Phone:518-421-2332
Mailing Address - Fax:
Practice Address - Street 1:203 SARA CT
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12308-1074
Practice Address - Country:US
Practice Address - Phone:518-421-2332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY174400000XOther17 - OTHER SERVICE PROVIDER