Provider Demographics
NPI:1043774177
Name:MITCHELL, REBECCA ELYSE
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ELYSE
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 1:932 FULTON ST E APT 1
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3565
Mailing Address - Country:US
Mailing Address - Phone:616-828-3065
Mailing Address - Fax:
Practice Address - Street 1:932 FULTON ST E APT 1
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3565
Practice Address - Country:US
Practice Address - Phone:616-828-3065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302044638390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program