1104552421 NPI number — MRS. MIRANDA JO MITCHELL FNP-C

Table of content: MRS. MIRANDA JO MITCHELL FNP-C (NPI 1104552421)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104552421 NPI number — MRS. MIRANDA JO MITCHELL FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITCHELL
Provider First Name:
MIRANDA
Provider Middle Name:
JO
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
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:
1104552421
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 N WABASH AVE STE G-20
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46952-2605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-660-7600
Provider Business Mailing Address Fax Number:
765-651-7313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1130 N BALDWIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46952-2536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-660-7480
Provider Business Practice Location Address Fax Number:
765-662-1259
Provider Enumeration Date:
07/28/2022

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: 363L00000X , with the licence number:  28235947A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com