Provider Demographics
NPI:1093565814
Name:FIORELLA-CRANDALL, MITCHELL
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:FIORELLA-CRANDALL
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 1:114 BONNETT AVE
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-6846
Mailing Address - Country:US
Mailing Address - Phone:716-984-8589
Mailing Address - Fax:
Practice Address - Street 1:77 GOODELL ST STE 340
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1243
Practice Address - Country:US
Practice Address - Phone:716-645-9707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program