=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154983492
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. CASSANDRA DENESE MITCHELL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2019
-----------------------------------------------------
Last Update Date | 07/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8319 HEIGHTS VLY
-----------------------------------------------------
City | CONVERSE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78109-3503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-537-2314
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8319 HEIGHTS VLY
-----------------------------------------------------
City | CONVERSE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78109-3503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-537-2314
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------