Provider Demographics
NPI:1043782139
Name:MITCHELL, DONNETTA MONIQUE (HAIR LOSS SPECIALIST)
Entity Type:Individual
Prefix:MRS
First Name:DONNETTA
Middle Name:MONIQUE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6724 SAILORS CREEK CT
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-8064
Mailing Address - Country:US
Mailing Address - Phone:804-317-3787
Mailing Address - Fax:
Practice Address - Street 1:6724 SAILORS CREEK CT
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-8064
Practice Address - Country:US
Practice Address - Phone:804-317-3787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-30
Last Update Date:2018-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA12040201941744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management