Provider Demographics
NPI:1659597185
Name:MITCHELL, JEANETTE OPHELIA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MISS
First Name:JEANETTE
Middle Name:OPHELIA
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:577 WYNDHOLME WAY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-3290
Mailing Address - Country:US
Mailing Address - Phone:443-831-1835
Mailing Address - Fax:
Practice Address - Street 1:8337 CHERRY LN
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4828
Practice Address - Country:US
Practice Address - Phone:667-367-8735
Practice Address - Fax:443-317-2996
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR137979363LP0808X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD021086200Medicaid