Basic Information
Provider Information | |||||||||
NPI: | 1639599277 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VITALE | ||||||||
FirstName: | ERIN | ||||||||
MiddleName: | GARDNER | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN, BSN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GARDNER | ||||||||
OtherFirstName: | ERIN | ||||||||
OtherMiddleName: | MICHELLE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN, BSN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1 WYOMING ST | ||||||||
Address2: |   | ||||||||
City: | DAYTON | ||||||||
State: | OH | ||||||||
PostalCode: | 454092722 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9372088394 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3535 SOUTHERN BLVD | ||||||||
Address2: |   | ||||||||
City: | KETTERING | ||||||||
State: | OH | ||||||||
PostalCode: | 454291221 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9373956665 | ||||||||
FaxNumber: | 9373956668 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/22/2014 | ||||||||
LastUpdateDate: | 11/16/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/16/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | RN356439 | OH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2200X | APRN.CNP.16273 | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
ID | Type | State | Issuer | Description | 0107049 | 05 | OH |   | MEDICAID |