Provider Demographics
NPI:1942807003
Name:VAVRINYUK, VITALY (RN)
Entity Type:Individual
Prefix:
First Name:VITALY
Middle Name:
Last Name:VAVRINYUK
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 VETERANS PL UNIT E-104
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-6900
Mailing Address - Country:US
Mailing Address - Phone:253-306-2691
Mailing Address - Fax:
Practice Address - Street 1:300 WEST AVE
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14853-6002
Practice Address - Country:US
Practice Address - Phone:607-254-4636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY746036163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics