Provider Demographics
NPI:1780187963
Name:VITALE, NICOLE (DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:VITALE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:RANALDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-4535
Mailing Address - Country:US
Mailing Address - Phone:631-467-4235
Mailing Address - Fax:631-467-2655
Practice Address - Street 1:141 MARK TREE RD
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-2221
Practice Address - Country:US
Practice Address - Phone:631-467-4235
Practice Address - Fax:631-467-2655
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040928-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist