Provider Demographics
NPI:1972852192
Name:VITALE, LYNN (DC)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:VITALE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 JUNGERMANN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-2774
Mailing Address - Country:US
Mailing Address - Phone:636-317-6311
Mailing Address - Fax:636-317-6312
Practice Address - Street 1:500 JUNGERMANN RD STE 200
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-2774
Practice Address - Country:US
Practice Address - Phone:636-317-6311
Practice Address - Fax:636-317-6312
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-04
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012030950111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor