MEDICARE: SHAUNNA SUE MITCHELL D.O.

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	207Q00000X	Family Medicine Physician	J6602	TX

General Provider Information

NPI Number	:	1457440034
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAUNNA SUE MITCHELL D.O.

Provider Business Mailing Address
First Line	:	4002 TECHNOLOGY CTR
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75605-2697
Country	:	US
Telephone Number	:	903-247-0484
Fax Number	:	903-247-0485

Provider Business Practice Location Address
First Line	:	402 N KAUFMAN ST
Second Line	:
City	:	LINDEN
State	:	TX
Zip	:	75563-5234
Country	:	US
Telephone Number	:	903-756-5581
Fax Number	:	903-756-5005

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

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	05/30/2023

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