Provider Demographics
NPI:1326622838
Name:MITCHELL, AUDREY SMITH
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:SMITH
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10811 SANDALWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75228-2410
Mailing Address - Country:US
Mailing Address - Phone:254-366-2300
Mailing Address - Fax:
Practice Address - Street 1:408 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITESBORO
Practice Address - State:TX
Practice Address - Zip Code:76273-1641
Practice Address - Country:US
Practice Address - Phone:903-816-3657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX86010048133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered