Provider Demographics
NPI:1134205750
Name:VITALE, SUSAN ANN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANN
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 1:120 PLANT AVE
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-3805
Mailing Address - Country:US
Mailing Address - Phone:631-851-3810
Mailing Address - Fax:631-273-4342
Practice Address - Street 1:120 PLANT AVE
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-3805
Practice Address - Country:US
Practice Address - Phone:631-851-3810
Practice Address - Fax:631-273-4342
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300786-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS72133Medicare ID - Type Unspecified