Provider Demographics
NPI:1154153211
Name:VITALITY-WELLNESS NURSE PRACTITIONER IN PSYCHIATRY AND FAMILY HEALTH P
Entity type:Organization
Organization Name:VITALITY-WELLNESS NURSE PRACTITIONER IN PSYCHIATRY AND FAMILY HEALTH P
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP-BC
Authorized Official - Prefix:DR
Authorized Official - First Name:EKAETE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWAL
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:646-856-9036
Mailing Address - Street 1:110 JERICHO TPKE STE 212
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001-2019
Mailing Address - Country:US
Mailing Address - Phone:646-856-9036
Mailing Address - Fax:
Practice Address - Street 1:110 JERICHO TPKE STE 212
Practice Address - Street 2:
Practice Address - City:FLORAL PARK
Practice Address - State:NY
Practice Address - Zip Code:11001-2019
Practice Address - Country:US
Practice Address - Phone:646-856-9036
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-16
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty