Provider Demographics
NPI:1235553538
Name:MITCHELL, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
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 1:703 BELLSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-5284
Mailing Address - Country:US
Mailing Address - Phone:904-386-3901
Mailing Address - Fax:
Practice Address - Street 1:5150 TIMUQUANA RD. # 14
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210
Practice Address - Country:US
Practice Address - Phone:904-386-3901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-07
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health