Provider Demographics
NPI:1174077267
Name:VITALE, ELISABETH (LAC)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:
Last Name:VITALE
Suffix:
Gender:F
Credentials:LAC
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 333
Mailing Address - Street 2:
Mailing Address - City:AMITY
Mailing Address - State:OR
Mailing Address - Zip Code:97101-0333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34950 BROOTEN RD
Practice Address - Street 2:
Practice Address - City:PACIFIC CITY
Practice Address - State:OR
Practice Address - Zip Code:97135-8034
Practice Address - Country:US
Practice Address - Phone:919-667-4676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-07
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC178684171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist