Provider Demographics
NPI:1245794387
Name:MITCHELL, STACEY LASANDRA (NP)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:LASANDRA
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:STACEY
Other - Middle Name:LASANDRA
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN, PMHNP-BC
Mailing Address - Street 1:1415 HIGHWAY 85 N STE 310-390
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:470-381-1502
Practice Address - Street 1:1255 HIGHWAY 54 W
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4526
Practice Address - Country:US
Practice Address - Phone:478-464-8134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY403153363LP0808X
GA203475363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1245794387OtherNPI