Healthcare Provider Details

I. General information

NPI: 1043782139
Provider Name (Legal Business Name): DONNETTA MONIQUE MITCHELL HAIR LOSS SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2018
Last Update Date: 12/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6724 SAILORS CREEK CT
CHESTERFIELD VA
23832-8064
US

IV. Provider business mailing address

6724 SAILORS CREEK CT
CHESTERFIELD VA
23832-8064
US

V. Phone/Fax

Practice location:
  • Phone: 804-317-3787
  • Fax:
Mailing address:
  • Phone: 804-317-3787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number1204020194
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: