MEDICARE: HALEY R MITCHELL

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	390200000X	Student in an Organized Health Care Education/Training Program	S12662	AL

General Provider Information

NPI Number	:	1477183986
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HALEY R MITCHELL

Provider Business Mailing Address
First Line	:	9676 AL HIGHWAY 28
Second Line	:
City	:	THOMASTON
State	:	AL
Zip	:	36783-3029
Country	:	US
Telephone Number	:	334-341-8422
Fax Number	:

Provider Business Practice Location Address
First Line	:	2320 MOORES MILL RD
Second Line	:
City	:	AUBURN
State	:	AL
Zip	:	36830-8402
Country	:	US
Telephone Number	:	334-887-8780
Fax Number	:

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

Provider Enumeration Date	:	01/23/2020
Last Update Date	:	01/23/2020

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