Provider Demographics
NPI:1689904542
Name:VITALE, MARY ALICE (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:VITALE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 GRANDE DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-5935
Mailing Address - Country:US
Mailing Address - Phone:850-477-7042
Mailing Address - Fax:850-474-9060
Practice Address - Street 1:4901 GRANDE DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-5935
Practice Address - Country:US
Practice Address - Phone:850-477-7042
Practice Address - Fax:850-474-9060
Is Sole Proprietor?:No
Enumeration Date:2009-12-28
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9198440367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL116035Medicaid
FLG006LOtherBLUE CROSS BLUE SHIELD
FL001981600Medicaid
P00846677OtherMEDICARE RAILROAD
AL592-10012OtherBLUE CROSS BLUE SHIELD
P00846677OtherMEDICARE RAILROAD