=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255169256
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TASHA MITCHELL LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2024
-----------------------------------------------------
Last Update Date | 07/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 655 KILLINGLY ST UNIT 1
-----------------------------------------------------
City | JOHNSTON
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02919-4059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-541-1381
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 91075
-----------------------------------------------------
City | JOHNSTON
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02919-0852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-541-1381
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 348463-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------