Healthcare Provider Details

I. General information

NPI: 1376190488
Provider Name (Legal Business Name): SRILATHA MITTAPELLI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2019
Last Update Date: 03/24/2025
Certification Date: 03/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 EAGLE DR
JACKSON MI
49201-9747
US

IV. Provider business mailing address

826 N MARTIN LUTHER KING JR DR
JACKSON MI
49202-2558
US

V. Phone/Fax

Practice location:
  • Phone: 517-416-8704
  • Fax:
Mailing address:
  • Phone: 800-379-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501019529
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502005826
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: