Basic Information
| Provider Information | |||||||||
| NPI: | 1619313020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | STACIE | ||||||||
| MiddleName: | COLLEEN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23 W GLANN RD | ||||||||
| Address2: | |||||||||
| City: | APALACHIN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137324026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077250889 | ||||||||
| FaxNumber: | 6076254251 | ||||||||
| Practice Location | |||||||||
| Address1: | 23 W GLANN RD | ||||||||
| Address2: | |||||||||
| City: | APALACHIN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137324026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077250889 | ||||||||
| FaxNumber: | 6076254251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2013 | ||||||||
| LastUpdateDate: | 02/27/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174H00000X | 006640 | NY | Y | Other Service Providers | Health Educator |
ID Information
| ID | Type | State | Issuer | Description | 03320656 | 05 | NY | MEDICAID |