Healthcare Provider Details

I. General information

NPI: 1659187300
Provider Name (Legal Business Name): MITTAL PATEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2024
Last Update Date: 12/07/2024
Certification Date: 12/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12228 PAXTON GLEN TER
GLEN ALLEN VA
23059-7166
US

IV. Provider business mailing address

12228 PAXTON GLEN TER
GLEN ALLEN VA
23059-7166
US

V. Phone/Fax

Practice location:
  • Phone: 805-504-6783
  • Fax:
Mailing address:
  • Phone: 805-504-6783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024187380
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number0001275667
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: