Provider Demographics
NPI:1386083046
Name:VITALE, CANDICE LYNNE (NP)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:LYNNE
Last Name:VITALE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:29275 NORTHWESTERN HWY
Mailing Address - Street 2:STE 100
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034
Mailing Address - Country:US
Mailing Address - Phone:877-784-3667
Mailing Address - Fax:248-869-3982
Practice Address - Street 1:43475 DALCOMA DRIVE
Practice Address - Street 2:STE 150
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038
Practice Address - Country:US
Practice Address - Phone:877-784-3667
Practice Address - Fax:248-869-3982
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704277903363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner