Provider Demographics
NPI:1487931861
Name:VITALE, MARY V (RN)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:V
Last Name:VITALE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6334 W BELOIT RD
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53219-1439
Mailing Address - Country:US
Mailing Address - Phone:414-364-7151
Mailing Address - Fax:
Practice Address - Street 1:11101 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-1133
Practice Address - Country:US
Practice Address - Phone:414-328-3764
Practice Address - Fax:414-328-3737
Is Sole Proprietor?:No
Enumeration Date:2011-11-13
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI144463-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse