Healthcare Provider Details

I. General information

NPI: 1669918991
Provider Name (Legal Business Name): TAMMY MICHELLE MITCHELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2017
Last Update Date: 01/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 NIRA ST
JACKSONVILLE FL
32207-8652
US

IV. Provider business mailing address

1860 MALTESE PL
MIDDLEBURG FL
32068-3143
US

V. Phone/Fax

Practice location:
  • Phone: 904-387-4991
  • Fax:
Mailing address:
  • Phone: 904-626-9778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9394143
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: