Provider Demographics
NPI:1346494903
Name:MITCHELL, DELVENIA RENEE
Entity Type:Individual
Prefix:MRS
First Name:DELVENIA
Middle Name:RENEE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 N PEARL ST APT 2
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206
Mailing Address - Country:US
Mailing Address - Phone:904-365-0799
Mailing Address - Fax:
Practice Address - Street 1:4515 N PEARL ST APT 2
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206
Practice Address - Country:US
Practice Address - Phone:904-365-0799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-10
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL693492797174400000X
FL693492796174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL693492797Medicaid
FL693492796Medicaid