1588024285 NPI number — MRS. KERRYROSE JOYCEANN MITCHELL A.R.N.P.

Table of content: MRS. KERRYROSE JOYCEANN MITCHELL A.R.N.P. (NPI 1588024285)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588024285 NPI number — MRS. KERRYROSE JOYCEANN MITCHELL A.R.N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITCHELL
Provider First Name:
KERRYROSE
Provider Middle Name:
JOYCEANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
A.R.N.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GORDON
Provider Other First Name:
KERRYROSE
Provider Other Middle Name:
JOYCEANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1588024285
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7800 SW 87TH AVENUE
Provider Second Line Business Mailing Address:
SUITE C-340
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33173
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-595-0109
Provider Business Mailing Address Fax Number:
305-595-7092

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 NORTH HIATUS ROAD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
PEMBROKE PINES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-431-0540
Provider Business Practice Location Address Fax Number:
954-431-0520
Provider Enumeration Date:
02/24/2016

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: 163W00000X , with the licence number:  ARNP9287130 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 9287130 , 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: 118801000 . 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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