Healthcare Provider Details

I. General information

NPI: 1669307625
Provider Name (Legal Business Name): MADONNA NICHOLE MITCHELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1216 GRANBY ST STE 204
NORFOLK VA
23510-2622
US

IV. Provider business mailing address

1612 SHELL RD
CHESAPEAKE VA
23323-6113
US

V. Phone/Fax

Practice location:
  • Phone: 757-386-0235
  • Fax:
Mailing address:
  • Phone: 757-386-0235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0906016800
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: