Provider Demographics
NPI:1639705494
Name:MITCHELL, MADISON ROSE
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:ROSE
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 1:44 PORTER RD
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2021
Mailing Address - Country:US
Mailing Address - Phone:973-803-0401
Mailing Address - Fax:
Practice Address - Street 1:1971 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24515-0002
Practice Address - Country:US
Practice Address - Phone:973-803-0401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-12
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer