Provider Demographics
NPI:1710404892
Name:VITALITY WELLNESS INSTITUTE
Entity Type:Organization
Organization Name:VITALITY WELLNESS INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALIST
Authorized Official - Prefix:
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:
Authorized Official - Last Name:NAFUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-901-1957
Mailing Address - Street 1:PO BOX 21833
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4115
Mailing Address - Country:US
Mailing Address - Phone:386-313-5287
Mailing Address - Fax:
Practice Address - Street 1:214 HIGHWAY 3086
Practice Address - Street 2:
Practice Address - City:JENKINS
Practice Address - State:KY
Practice Address - Zip Code:41537
Practice Address - Country:US
Practice Address - Phone:276-220-2408
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-29
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006206363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100100220Medicaid