Provider Demographics
NPI:1518261197
Name:VITTITOW, SHIRLEY M (APRN)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:M
Last Name:VITTITOW
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9800 SHELBYVILLE RD STE 220
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-2992
Mailing Address - Country:US
Mailing Address - Phone:502-429-8585
Mailing Address - Fax:502-429-6157
Practice Address - Street 1:9800 SHELBYVILLE RD STE 220
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-2992
Practice Address - Country:US
Practice Address - Phone:502-429-8585
Practice Address - Fax:502-429-6157
Is Sole Proprietor?:No
Enumeration Date:2010-12-22
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN7100268660363L00000X
IN71004927A363L00000X
KY3006555363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100268660Medicaid
IN300003723Medicaid