=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730808775
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALYSSA M MITCHELL MS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2022
-----------------------------------------------------
Last Update Date | 11/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8697 S BEN ROWE CIR
-----------------------------------------------------
City | MACCLENNY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32063-5117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-553-9782
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8697 S BEN ROWE CIR
-----------------------------------------------------
City | MACCLENNY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32063-5117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-553-9782
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SA22624
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------