Provider Demographics
NPI:1639628753
Name:MITCHELL, MARY POULIAS (NP-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:POULIAS
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:L
Other - Last Name:POULIAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:5 NEPONSET ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-2714
Mailing Address - Country:US
Mailing Address - Phone:508-368-5532
Mailing Address - Fax:
Practice Address - Street 1:165 MILL ST
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-3289
Practice Address - Country:US
Practice Address - Phone:978-468-3208
Practice Address - Fax:978-840-1680
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-30
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2280889363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily