Healthcare Provider Details

I. General information

NPI: 1861303729
Provider Name (Legal Business Name): MRS. MASEYREE MITCHELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 BRAMBLE BUSH TRL
COVINGTON GA
30014-5972
US

IV. Provider business mailing address

125 BRAMBLE BUSH TRL
COVINGTON GA
30014-5972
US

V. Phone/Fax

Practice location:
  • Phone: 678-576-2768
  • Fax:
Mailing address:
  • Phone: 678-576-2768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335G00000X
TaxonomyMedical Foods Supplier
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: