Provider Demographics
NPI:1821517954
Name:VITALITY FUNCTIONAL MEDICINE LLC
Entity Type:Organization
Organization Name:VITALITY FUNCTIONAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:ARNOLD
Authorized Official - Last Name:BISHOP
Authorized Official - Suffix:
Authorized Official - Credentials:GNP-BC, FNP-C
Authorized Official - Phone:561-676-6121
Mailing Address - Street 1:19657 ASPEN RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3366
Mailing Address - Country:US
Mailing Address - Phone:561-676-6121
Mailing Address - Fax:
Practice Address - Street 1:155 SW CENTURY DR STE 111
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1657
Practice Address - Country:US
Practice Address - Phone:458-206-3331
Practice Address - Fax:620-506-4777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201706673NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty