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General NPI Number Information
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NPI Number | 1295750677
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Entity Type | Individual
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Provider Name | INGRID DOMINIC MITCHELL P.A.
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Gender | Female
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Dates
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Enumeration Date | 07/13/2006
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Last Update Date | 06/01/2016
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Provider Practice Location Address
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Address Line | 18254 LIVERNOIS AVE STE 1
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City | DETROIT
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State | MI
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Zip | 48221-4214
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Country | US
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Telephone | 313-861-4400
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Fax | 248-336-9137
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Provider Business Mailing Address
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Address Line | 390 ENTERPRISE CT SUITE 103
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City | BLOOMFIELD HILLS
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State | MI
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Zip | 48302-0320
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Country | US
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Telephone | 248-336-4000
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Fax | 248-336-9137
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 5601003504
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License Number State | MI
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