Provider Demographics
NPI:1053854885
Name:MITCHELL, CASEY (MS, RD, CD)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MS, RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W12802 COUNTY ROAD A
Mailing Address - Street 2:
Mailing Address - City:BOWLER
Mailing Address - State:WI
Mailing Address - Zip Code:54416-9551
Mailing Address - Country:US
Mailing Address - Phone:715-793-5006
Mailing Address - Fax:
Practice Address - Street 1:W12802 COUNTY ROAD A
Practice Address - Street 2:
Practice Address - City:BOWLER
Practice Address - State:WI
Practice Address - Zip Code:54416-9551
Practice Address - Country:US
Practice Address - Phone:715-793-5006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3052-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered