Basic Information
| Provider Information | |||||||||
| NPI: | 1518261197 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VITTITOW | ||||||||
| FirstName: | SHIRLEY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9800 SHELBYVILLE RD STE 220 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402232992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024298585 | ||||||||
| FaxNumber: | 5024296157 | ||||||||
| Practice Location | |||||||||
| Address1: | 9800 SHELBYVILLE RD STE 220 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402232992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024298585 | ||||||||
| FaxNumber: | 5024296157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2010 | ||||||||
| LastUpdateDate: | 05/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 7100268660 | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 71004927A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 3006555 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 3006555 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7100268660 | 05 | KY | MEDICAID | 300003723 | 05 | IN | MEDICAID |