MEDICARE: VITALITY NP FAMILY HEALTH PC

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	363LF0000X	Family Nurse Practitioner	482054	NY

General Provider Information

NPI Number	:	1649668153
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALITY NP FAMILY HEALTH PC

Provider Business Mailing Address
First Line	:	2912 BRIGHTON 12TH ST STE 1
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-4722
Country	:	US
Telephone Number	:	718-975-0657
Fax Number	:	718-975-4337

Provider Business Practice Location Address
First Line	:	1009 BRIGHTON BEACH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-5659
Country	:	US
Telephone Number	:	718-975-0657
Fax Number	:	718-975-4337

Authorized Official
Title or Position	:	OWENER
Name	:	SVETLANA PYATIGORSKAYA
Credential	:	NP
Telephone Number	:	718-975-0657

Provider Enumeration Date	:	01/06/2015
Last Update Date	:	01/06/2015

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