Provider Demographics
NPI:1174132112
Name:MITCHELL, ALISON RENEE
Entity type:Individual
Prefix:
First Name:ALISON
Middle Name:RENEE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 DRIVE 1347
Mailing Address - Street 2:
Mailing Address - City:MOOREVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38857-7439
Mailing Address - Country:US
Mailing Address - Phone:662-322-4047
Mailing Address - Fax:
Practice Address - Street 1:201 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-3917
Practice Address - Country:US
Practice Address - Phone:662-432-4106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS862935363L00000X
MSMITC-BK3CE9363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner