Provider Demographics
NPI:1871193292
Name:VITAL-HERNE, PAULETTE
Entity Type:Individual
Prefix:
First Name:PAULETTE
Middle Name:
Last Name:VITAL-HERNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8427 HUNTERS FORK LOOP
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33573-0159
Mailing Address - Country:US
Mailing Address - Phone:813-679-5413
Mailing Address - Fax:
Practice Address - Street 1:5381 PRIMROSE LAKE CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3521
Practice Address - Country:US
Practice Address - Phone:813-615-2492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11009426363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health