Provider Demographics
NPI:1497393490
Name:MITCHELL, WILLIE M
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:M
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 FRIENDLY RD
Mailing Address - Street 2:
Mailing Address - City:DUNN
Mailing Address - State:NC
Mailing Address - Zip Code:28334-2904
Mailing Address - Country:US
Mailing Address - Phone:910-514-6653
Mailing Address - Fax:
Practice Address - Street 1:1106 FRIENDLY RD
Practice Address - Street 2:
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334-2904
Practice Address - Country:US
Practice Address - Phone:910-514-6653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-20
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC37204441172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver