Healthcare Provider Details

I. General information

NPI: 1326622838
Provider Name (Legal Business Name): AUDREY SMITH MITCHELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AUDREY SMITH

II. Dates (important events)

Enumeration Date: 05/11/2021
Last Update Date: 05/11/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 W MAIN ST
WHITESBORO TX
76273-1641
US

IV. Provider business mailing address

10811 SANDALWOOD DR
DALLAS TX
75228-2410
US

V. Phone/Fax

Practice location:
  • Phone: 903-816-3657
  • Fax:
Mailing address:
  • Phone: 254-366-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86010048
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: