Provider Demographics
NPI:1285640227
Name:MITCHELL, JOHNNIE LARA (ACNP-BC, RNFA)
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:LARA
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:ACNP-BC, RNFA
Other - Prefix:
Other - First Name:J
Other - Middle Name:LARA
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ACNP-BC, RNFA
Mailing Address - Street 1:12259 150TH CT N
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33478-3513
Mailing Address - Country:US
Mailing Address - Phone:561-748-7212
Mailing Address - Fax:
Practice Address - Street 1:12259 150TH CT N
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33478-3513
Practice Address - Country:US
Practice Address - Phone:561-748-7212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2831402163W00000X, 163WR0006X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDQ764Medicare UPIN