Provider Demographics
NPI:1417140757
Name:MITCHELL, VALERIE MICHELLE (CRNA)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:MICHELLE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2529
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-383-4752
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:ANESTHESIOLOGY
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2529
Practice Address - Country:US
Practice Address - Phone:217-383-3303
Practice Address - Fax:217-383-3265
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006717367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL$$$$$$$$$001Medicaid
ILK40453Medicare PIN
K40453Medicare UPIN
IL6447860011Medicare NSC