Provider Demographics
NPI:1073910857
Name:MITCHELL, KIAH (LPN)
Entity Type:Individual
Prefix:MS
First Name:KIAH
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 CAROLINE AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-1226
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:723 CAROLINE AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-1226
Practice Address - Country:US
Practice Address - Phone:516-872-4251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-22
Last Update Date:2014-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY299726-1313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility