MEDICARE: MS. MARY CHANTAY MITCHELL FNP-C

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	28299	TN

General Provider Information

NPI Number	:	1174123632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY CHANTAY MITCHELL FNP-C

Provider Business Mailing Address
First Line	:	3342 CARIBOU DR
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38115-3006
Country	:	US
Telephone Number	:	901-289-3611
Fax Number	:

Provider Business Practice Location Address
First Line	:	3342 CARIBOU DR
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38115-3006
Country	:	US
Telephone Number	:	901-289-3611
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2020
Last Update Date	:	01/25/2021

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