Basic Information
| Provider Information | |||||||||
| NPI: | 1801343066 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | KATHRYN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCKEAN | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | KATHRYN | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1510 | ||||||||
| Address2: | |||||||||
| City: | EAU CLAIRE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547021510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087850940 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 310 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPARTA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546562170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082691770 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2016 | ||||||||
| LastUpdateDate: | 09/15/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 7232-33 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 7232-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.