Healthcare Provider Details

I. General information

NPI: 1316284011
Provider Name (Legal Business Name): NICOLE SHONTREASE MITCHELL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2013
Last Update Date: 05/29/2023
Certification Date: 05/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N 1ST ST ANESTHESIA DEPT
SPRINGFIELD IL
62781-0001
US

IV. Provider business mailing address

1117 N OLIVE AVE STE 203
WEST PALM BEACH FL
33401-3520
US

V. Phone/Fax

Practice location:
  • Phone: 217-788-3755
  • Fax: 217-788-7071
Mailing address:
  • Phone: 217-788-3755
  • Fax: 217-788-7071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9402261
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209010168
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA000564
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: