Provider Demographics
NPI:1396104246
Name:VITAL, KATHERINE LAVILLA (CRNA)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:LAVILLA
Last Name:VITAL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:BABAN
Other - Last Name:LAVILLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2708 TIMBERGROVE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34771-9318
Mailing Address - Country:US
Mailing Address - Phone:305-761-8078
Mailing Address - Fax:
Practice Address - Street 1:1613 HARRISON PKWY
Practice Address - Street 2:BUILDING C SUITE 200
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-2896
Practice Address - Country:US
Practice Address - Phone:954-838-2371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-22
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9228533367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered