Healthcare Provider Details

I. General information

NPI: 1205802451
Provider Name (Legal Business Name): SANDRA RODRIGUEZ MITCHELL NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 LAKE MANOR DR
KINGSLAND GA
31548-6274
US

IV. Provider business mailing address

148 LAKE MANOR DR
KINGSLAND GA
31548-6274
US

V. Phone/Fax

Practice location:
  • Phone: 912-573-4220
  • Fax:
Mailing address:
  • Phone: 912-573-4220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number260444
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: