Provider Demographics
NPI:1831694090
Name:VITALE, KIMBERLY RENE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RENE
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 1:4019 PASEO ROYALE BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-8256
Mailing Address - Country:US
Mailing Address - Phone:850-221-7217
Mailing Address - Fax:
Practice Address - Street 1:16605 SOUTHWEST FWY
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-3501
Practice Address - Country:US
Practice Address - Phone:281-274-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX798641363LA2100X
TXAP137051363LA2100X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care