Provider Demographics
NPI:1033599337
Name:MITCHELL, MARTHA ANN
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:ANN
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 1:1078 BETTY DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-5431
Mailing Address - Country:US
Mailing Address - Phone:336-671-6125
Mailing Address - Fax:
Practice Address - Street 1:1078 BETTY DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-5431
Practice Address - Country:US
Practice Address - Phone:336-671-6125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-02
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X
NC175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No175T00000XOther Service ProvidersPeer Specialist