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NPI Code Detail

MEDICARE: KIMBERLY J MITCHELL

MEDICARE: KIMBERLY J MITCHELL
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
1363L00000XNurse Practitioner209018150IL
2363LF0000XFamily Nurse Practitioner209.018150IL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1209.018150OTHERIL.
22019026962OTHERMOSTATE LICENSE MO

General Provider Information

NPI Number : 1700350170
Entity Type Code : Individual
Provider Name (Legal Business Name) : KIMBERLY J MITCHELL
Provider Business Mailing Address
First Line : PO BOX 746715
Second Line :
City : ATLANTA
State : GA
Zip : 30374-6715
Country : US
Telephone Number : 773-352-1515
Fax Number : 312-929-0373
Provider Business Practice Location Address
First Line : 2420 STATE ST
Second Line :
City : EAST SAINT LOUIS
State : IL
Zip : 62205-2321
Country : US
Telephone Number : 618-318-8809
Fax Number : 618-615-4205
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/18/2019
Last Update Date : 06/06/2025

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Directions to “ KIMBERLY J MITCHELL ” Practice Location

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