Healthcare Provider Details

I. General information

NPI: 1285452490
Provider Name (Legal Business Name): SAMANTHA LYNN MITCHELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GRAND ST
NEW BRITAIN CT
06052-2016
US

IV. Provider business mailing address

1290 SILAS DEANE HWY
WETHERSFIELD CT
06109-4337
US

V. Phone/Fax

Practice location:
  • Phone: 860-224-5011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number23.006656
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number23.006656
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: