Provider Demographics
NPI:1013133826
Name:PACK, VITIA ANGELA (PA-C)
Entity type:Individual
Prefix:
First Name:VITIA
Middle Name:ANGELA
Last Name:PACK
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 HOSIERY MILL RD STE 124
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-1688
Mailing Address - Country:US
Mailing Address - Phone:770-443-6111
Mailing Address - Fax:
Practice Address - Street 1:49 HOSIERY MILL RD STE 124
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-1688
Practice Address - Country:US
Practice Address - Phone:770-443-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225700000X
FLPA9106235363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA31540OtherLICENSE NUMBER