Healthcare Provider Details

I. General information

NPI: 1922537745
Provider Name (Legal Business Name): TRACY LYNN MITCHEL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 06/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 EAST BLVD
ELKHART IN
46514-2483
US

IV. Provider business mailing address

PO BOX 419569
BOSTON MA
02241-9569
US

V. Phone/Fax

Practice location:
  • Phone: 574-294-2621
  • Fax:
Mailing address:
  • Phone: 574-523-3160
  • Fax: 574-523-3221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number28129890A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: