Healthcare Provider Details

I. General information

NPI: 1801368618
Provider Name (Legal Business Name): TRACIE MICHELLE MITCHELL CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: T. MITCHELL T. MITCHELL,MSN CRNP

II. Dates (important events)

Enumeration Date: 12/19/2018
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 SOUTH ST E
TALLADEGA AL
35160-2621
US

IV. Provider business mailing address

1004 SOUTH ST E STE A
TALLADEGA AL
35160-2621
US

V. Phone/Fax

Practice location:
  • Phone: 256-493-6402
  • Fax:
Mailing address:
  • Phone: 256-362-2013
  • Fax: 256-362-2015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number1-072535
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-072535
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number1-072535
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: