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General NPI Number Information
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NPI Number | 1104776939
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Entity Type | Organization
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Legal Business Name | PHOENIX VITALITY, LLC
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Dates
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Enumeration Date | 01/31/2026
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Last Update Date | 01/31/2026
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Provider Practice Location Address
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Address Line | 603 E MAIN ST
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City | LEIPSIC
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State | OH
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Zip | 45856-1438
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Country | US
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Telephone | 419-957-9737
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Fax |
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Provider Business Mailing Address
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Address Line | 603 E MAIN ST
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City | LEIPSIC
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State | OH
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Zip | 45856-1438
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Country | US
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Telephone | 419-957-9737
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | STEPHANIE LYNN RODRIGUEZ
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Credential | CNP
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Telephone | 419-957-0631
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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