Healthcare Provider Details

I. General information

NPI: 1356557466
Provider Name (Legal Business Name): MRS. JUANITA LYNN MITCHELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 3RD AVE
HEWITT MN
56453-0015
US

IV. Provider business mailing address

508 3RD AVE P.O.BOX 15
HEWITT MN
56453-0015
US

V. Phone/Fax

Practice location:
  • Phone: 218-924-4179
  • Fax:
Mailing address:
  • Phone: 218-924-4179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number222078-2-AFC
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: