MEDICARE: VITA FIDELIS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1568333078
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITA FIDELIS LLC

Provider Business Mailing Address
First Line	:	879 PARK AVE W
Second Line	:
City	:	MANSFIELD
State	:	OH
Zip	:	44906-2944
Country	:	US
Telephone Number	:	760-458-5111
Fax Number	:	419-709-9044

Provider Business Practice Location Address
First Line	:	879 PARK AVE W
Second Line	:
City	:	MANSFIELD
State	:	OH
Zip	:	44906-2944
Country	:	US
Telephone Number	:	760-458-5111
Fax Number	:	419-709-9044

Authorized Official
Title or Position	:	OWNER
Name	:	PAMELA LUCILLE KASS
Credential	:	PMHNP-BC
Telephone Number	:	760-458-5111

Provider Enumeration Date	:	09/16/2025
Last Update Date	:	12/05/2025

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Directions to “VITA FIDELIS LLC ” Practice Location

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