Provider Demographics
NPI:1578133708
Name:MITCHELL, TESHA
Entity Type:Individual
Prefix:
First Name:TESHA
Middle Name:
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 1:32 POLITE FAMILY LN
Mailing Address - Street 2:
Mailing Address - City:SEABROOK
Mailing Address - State:SC
Mailing Address - Zip Code:29940-2906
Mailing Address - Country:US
Mailing Address - Phone:184-344-1260
Mailing Address - Fax:
Practice Address - Street 1:32 POLITE FAMILY LN
Practice Address - Street 2:
Practice Address - City:SEABROOK
Practice Address - State:SC
Practice Address - Zip Code:29940-2906
Practice Address - Country:US
Practice Address - Phone:184-344-1260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC6073672301Medicaid