Provider Demographics
NPI:1174123632
Name:MITCHELL, MARY CHANTAY (FNP-C)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:CHANTAY
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3342 CARIBOU DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-3006
Mailing Address - Country:US
Mailing Address - Phone:901-289-3611
Mailing Address - Fax:
Practice Address - Street 1:3342 CARIBOU DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-3006
Practice Address - Country:US
Practice Address - Phone:901-289-3611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28299363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily