Provider Demographics
NPI:1043845712
Name:VITOLO, KELLEY WIDEL (CSFA)
Entity type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:WIDEL
Last Name:VITOLO
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411 LONDONDERRY CT
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-5059
Mailing Address - Country:US
Mailing Address - Phone:336-327-9175
Mailing Address - Fax:
Practice Address - Street 1:3411 LONDONDERRY CT
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-5059
Practice Address - Country:US
Practice Address - Phone:336-327-9175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant