Healthcare Provider Details

I. General information

NPI: 1396782223
Provider Name (Legal Business Name): COLLEEN CONCANNON VITALE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COLLEEN ROBYN CONCANNON M.D.

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 08/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 RESERVOIR AVE
CRANSTON RI
02920-6055
US

IV. Provider business mailing address

1145 RESERVOIR AVE
CRANSTON RI
02920-6055
US

V. Phone/Fax

Practice location:
  • Phone: 401-943-7337
  • Fax:
Mailing address:
  • Phone: 401-943-7337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12102
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: