Healthcare Provider Details

I. General information

NPI: 1124035399
Provider Name (Legal Business Name): DIANE L. MITCHELL P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 08/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 TALBOTTON RD
COLUMBUS GA
31904-8749
US

IV. Provider business mailing address

1130 TALBOTTON RD
COLUMBUS GA
31904-8749
US

V. Phone/Fax

Practice location:
  • Phone: 706-327-0700
  • Fax: 706-327-0757
Mailing address:
  • Phone: 706-641-6900
  • Fax: 706-327-0757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004787
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: