Provider Demographics
NPI:1952079485
Name:BALISTA, VITA MERYLLE
Entity Type:Individual
Prefix:
First Name:VITA
Middle Name:MERYLLE
Last Name:BALISTA
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 1:100 WOODS RD
Mailing Address - Street 2:
Mailing Address - City:VALHALLA
Mailing Address - State:NY
Mailing Address - Zip Code:10595-1530
Mailing Address - Country:US
Mailing Address - Phone:914-493-7518
Mailing Address - Fax:
Practice Address - Street 1:100 WOODS RD
Practice Address - Street 2:
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595-1530
Practice Address - Country:US
Practice Address - Phone:914-493-7518
Practice Address - Fax:914-493-8130
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF347217-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily