Provider Demographics
NPI:1962088104
Name:VITALE-D'ANGELO, SABRINA PROVVIDENZA (CRNA)
Entity type:Individual
Prefix:
First Name:SABRINA
Middle Name:PROVVIDENZA
Last Name:VITALE-D'ANGELO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 359
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:IA
Mailing Address - Zip Code:52057-0359
Mailing Address - Country:US
Mailing Address - Phone:563-927-7457
Mailing Address - Fax:
Practice Address - Street 1:709 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:IA
Practice Address - Zip Code:52057-1526
Practice Address - Country:US
Practice Address - Phone:563-927-7457
Practice Address - Fax:563-927-7457
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD175517367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAD175517OtherSTATE LICENSE
IAMV8194843OtherDEA
IA5208192OtherCSA