Provider Demographics
NPI:1154891083
Name:VITALE, KATHRYN (MSN, APN, AGCNS-BC)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:VITALE
Suffix:
Gender:F
Credentials:MSN, APN, AGCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:881 BELMAR LN
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-1311
Mailing Address - Country:US
Mailing Address - Phone:847-922-4935
Mailing Address - Fax:
Practice Address - Street 1:800 N WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1673
Practice Address - Country:US
Practice Address - Phone:847-234-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.018304364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist