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General NPI Number Information
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NPI Number | 1992512479
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Entity Type | Individual
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Provider Name | MR. MARK TIMOTHY MITCHUM
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Gender | Male
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Dates
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Enumeration Date | 12/17/2024
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Last Update Date | 12/17/2024
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Provider Practice Location Address
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Address Line | 2022 BATTERY PARK DR
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City | GLENDALE
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State | KY
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Zip | 42740
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Country | US
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Telephone | 859-314-3670
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Fax |
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Provider Business Mailing Address
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Address Line | 311 HILLVIEW DR
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City | HORSE CAVE
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State | KY
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Zip | 42749-8048
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Country | US
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Telephone | 270-540-1080
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Fax |
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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 | 163WX0106X
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Taxonomy Name | Occupational Health Registered Nurse
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License Number | 1112028
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License Number State | KY
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