Healthcare Provider Details

I. General information

NPI: 1497197453
Provider Name (Legal Business Name): VALERIE REBECCA VITALE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VALERIE REBECCA BOOTH

II. Dates (important events)

Enumeration Date: 07/18/2013
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 PROSPERITY AVE STE D
FAIRFAX VA
22031-4330
US

IV. Provider business mailing address

13230 MAPLE CREEK LN
CENTREVILLE VA
20120-6105
US

V. Phone/Fax

Practice location:
  • Phone: 703-226-2290
  • Fax:
Mailing address:
  • Phone: 703-850-1072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001212690
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0024171021
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024171021
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: