Healthcare Provider Details

I. General information

NPI: 1528656584
Provider Name (Legal Business Name): CHARYL M MITCHELL MSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2021
Last Update Date: 01/05/2021
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13170 OLD JAMESTOWN RD
BLACK JACK MO
63033-4504
US

IV. Provider business mailing address

13170 OLD JAMESTOWN RD
BLACK JACK MO
63033-4504
US

V. Phone/Fax

Practice location:
  • Phone: 314-341-7297
  • Fax:
Mailing address:
  • Phone: 314-341-7297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number2008007319
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: