Provider Demographics
NPI:1396782223
Name:VITALE, COLLEEN CONCANNON (MD)
Entity type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:CONCANNON
Last Name:VITALE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:COLLEEN
Other - Middle Name:ROBYN
Other - Last Name:CONCANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1145 RESERVOIR AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-6055
Mailing Address - Country:US
Mailing Address - Phone:401-943-7337
Mailing Address - Fax:
Practice Address - Street 1:1145 RESERVOIR AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-6055
Practice Address - Country:US
Practice Address - Phone:401-943-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI12102208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics