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NPI Code Detail

MEDICARE: MRS. STACEY LASANDRA MITCHELL NP

MEDICARE: MRS. STACEY LASANDRA MITCHELL NP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363LP0808XPsychiatric/Mental Health Nurse Practitioner403153NY
2363LP0808XPsychiatric/Mental Health Nurse Practitioner203475GA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11245794387OTHERGANPI

General Provider Information

NPI Number : 1245794387
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. STACEY LASANDRA MITCHELL NP
Provider Business Mailing Address
First Line : 1415 HIGHWAY 85 N STE 310-390
Second Line :
City : FAYETTEVILLE
State : GA
Zip : 30214-7738
Country : US
Telephone Number :
Fax Number : 470-381-1502
Provider Business Practice Location Address
First Line : 320 LANIER AVE W STE 200
Second Line :
City : FAYETTEVILLE
State : GA
Zip : 30214-7443
Country : US
Telephone Number : 678-590-1232
Fax Number : 470-381-1502
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/23/2019
Last Update Date : 09/16/2024

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