1033603899 NPI number — DR. VANESSA MONIQUE MITCHELL MD

Table of content: DR. VANESSA MONIQUE MITCHELL MD (NPI 1033603899)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033603899 NPI number — DR. VANESSA MONIQUE MITCHELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITCHELL
Provider First Name:
VANESSA
Provider Middle Name:
MONIQUE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033603899
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/14/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 734951
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60673-4951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-899-0595
Provider Business Mailing Address Fax Number:
702-977-1496

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3487 NW 30TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAUDERDALE LAKES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33311-1103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
872-231-3162
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/15/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  ME151167 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 112508400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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