=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962286831
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARANDA MICHELLE MITCHELL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2023
-----------------------------------------------------
Last Update Date | 09/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 N MAIN ST STE 304
-----------------------------------------------------
City | CROWN POINT
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46307-1877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-546-1900
-----------------------------------------------------
Fax | 574-546-1999
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 548 S COUNTY ROAD 500 W
-----------------------------------------------------
City | CORY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47846-8074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-236-3531
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 71014229A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 71014229A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------