Healthcare Provider Details

I. General information

NPI: 1023791456
Provider Name (Legal Business Name): VONNIQUE MITCHELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2023
Last Update Date: 08/29/2025
Certification Date: 08/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 DAVIS ST STE 300
SAN LEANDRO CA
94577-6923
US

IV. Provider business mailing address

777 DAVIS ST
SAN LEANDRO CA
94577-6923
US

V. Phone/Fax

Practice location:
  • Phone: 510-839-3800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: