Provider Demographics
NPI:1245565662
Name:MITCHELL, KAITLYN (LAC)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 BELLVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11719-9705
Mailing Address - Country:US
Mailing Address - Phone:631-294-6017
Mailing Address - Fax:
Practice Address - Street 1:2 CORACI BLVD STE 5
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967-4833
Practice Address - Country:US
Practice Address - Phone:631-281-0606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-04
Last Update Date:2009-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004147171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist