Healthcare Provider Details

I. General information

NPI: 1295476737
Provider Name (Legal Business Name): MRS. TIFFANY ANGELICA VITALE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2022
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9924 AZALEA BLOOM WAY APT 214
RIVERVIEW FL
33578-4630
US

IV. Provider business mailing address

9924 AZALEA BLOOM WAY APT 214
RIVERVIEW FL
33578-4630
US

V. Phone/Fax

Practice location:
  • Phone: 813-766-8624
  • Fax:
Mailing address:
  • Phone: 813-766-8624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW27140
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: