Provider Demographics
NPI:1164411302
Name:MITCHELL, COURTNEY COMELLA (PAC)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:COMELLA
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:COMMELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2351 HUGUENARD DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503
Mailing Address - Country:US
Mailing Address - Phone:859-276-0191
Mailing Address - Fax:859-277-0466
Practice Address - Street 1:2351 HUGUENARD DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503
Practice Address - Country:US
Practice Address - Phone:859-276-0191
Practice Address - Fax:859-277-0466
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA923363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4000501OtherMEDICARE LAB GROUP
KYO54081Medicare UPIN
KY4000501OtherMEDICARE LAB GROUP