MEDICARE: VITAL VITA WELLNESS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LX0106X	Occupational Health Nurse Practitioner
2	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1598357733
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITAL VITA WELLNESS

Provider Business Mailing Address
First Line	:	1537 43RD ST
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407-3607
Country	:	US
Telephone Number	:	561-602-2682
Fax Number	:

Provider Business Practice Location Address
First Line	:	2620 N AUSTRALIAN AVE STE 109
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407-5625
Country	:	US
Telephone Number	:	754-457-8490
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ NURSE PRACTITIONER
Name	:	MISS TARANEISHA R BURGESS
Credential	:	APRN
Telephone Number	:	561-602-2682

Provider Enumeration Date	:	02/09/2021
Last Update Date	:	02/09/2021

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