Healthcare Provider Details

I. General information

NPI: 1598357733
Provider Name (Legal Business Name): VITAL VITA WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 02/09/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 N AUSTRALIAN AVE STE 109
WEST PALM BEACH FL
33407-5625
US

IV. Provider business mailing address

1537 43RD ST
WEST PALM BEACH FL
33407-3607
US

V. Phone/Fax

Practice location:
  • Phone: 754-457-8490
  • Fax:
Mailing address:
  • Phone: 561-602-2682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MISS TARANEISHA R BURGESS
Title or Position: OWNER/ NURSE PRACTITIONER
Credential: APRN
Phone: 561-602-2682