Healthcare Provider Details

I. General information

NPI: 1588735104
Provider Name (Legal Business Name): KORY LANCE MITCHELL ACUTE CARE NURSE PRA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3502 9TH ST STE 260
LUBBOCK TX
79415-5305
US

IV. Provider business mailing address

5219 CITY BANK PKWY STE 35
LUBBOCK TX
79407
US

V. Phone/Fax

Practice location:
  • Phone: 806-792-8185
  • Fax: 806-792-9180
Mailing address:
  • Phone: 806-761-0333
  • Fax: 806-782-0097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number663921
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP114881
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: