Provider Demographics
NPI:1891166914
Name:VITALE, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:VITALE
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 1:1000 DUNHAM DR
Mailing Address - Street 2:
Mailing Address - City:DUNMORE
Mailing Address - State:PA
Mailing Address - Zip Code:18512-2666
Mailing Address - Country:US
Mailing Address - Phone:570-687-0589
Mailing Address - Fax:
Practice Address - Street 1:1000 DUNHAM DR
Practice Address - Street 2:
Practice Address - City:DUNMORE
Practice Address - State:PA
Practice Address - Zip Code:18512-2666
Practice Address - Country:US
Practice Address - Phone:570-687-0589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN232653L163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency