Provider Demographics
NPI:1043843030
Name:MITCHELL, KEITH ALAN
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ALAN
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 KENILWORTH RD
Mailing Address - Street 2:
Mailing Address - City:NICHOLS HILLS
Mailing Address - State:OK
Mailing Address - Zip Code:73120-1410
Mailing Address - Country:US
Mailing Address - Phone:405-850-1378
Mailing Address - Fax:
Practice Address - Street 1:1309 KENILWORTH RD
Practice Address - Street 2:
Practice Address - City:NICHOLS HILLS
Practice Address - State:OK
Practice Address - Zip Code:73120-1410
Practice Address - Country:US
Practice Address - Phone:405-850-1378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator