Provider Demographics
NPI:1790404713
Name:VITALIY MEDICAL AESTHETICS
Entity Type:Organization
Organization Name:VITALIY MEDICAL AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:WANGARI
Authorized Official - Last Name:WAITHAKA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC,RN
Authorized Official - Phone:857-701-5425
Mailing Address - Street 1:10 DIXFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-1084
Mailing Address - Country:US
Mailing Address - Phone:857-701-5425
Mailing Address - Fax:508-373-2429
Practice Address - Street 1:10 DIXFIELD RD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-1084
Practice Address - Country:US
Practice Address - Phone:857-701-5425
Practice Address - Fax:508-373-2429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty