Provider Demographics
NPI:1174903942
Name:MITCHELL, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:LATREVA
Other - Middle Name:
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1108 MADISON PLZ STE 202
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-5166
Mailing Address - Country:US
Mailing Address - Phone:757-512-5565
Mailing Address - Fax:757-644-5337
Practice Address - Street 1:1108 MADISON PLZ STE 202
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-5166
Practice Address - Country:US
Practice Address - Phone:757-512-5565
Practice Address - Fax:757-644-5337
Is Sole Proprietor?:No
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1510097374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA463289095Medicaid