Healthcare Provider Details

I. General information

NPI: 1205181526
Provider Name (Legal Business Name): CONSTANCE MITCHELL NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 STOCKTON BLVD
SACRAMENTO CA
95817-2215
US

IV. Provider business mailing address

2425 STOCKTON BLVD
SACRAMENTO CA
95817-2215
US

V. Phone/Fax

Practice location:
  • Phone: 707-672-6536
  • Fax: 916-453-5038
Mailing address:
  • Phone: 707-672-6536
  • Fax: 916-453-5038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95009958
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN781915
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: