Provider Demographics
NPI:1679241459
Name:MITCHELL, DEMETRIA
Entity Type:Individual
Prefix:
First Name:DEMETRIA
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 1:1204 OVERMAN CIR APT C
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-4675
Mailing Address - Country:US
Mailing Address - Phone:252-455-6818
Mailing Address - Fax:
Practice Address - Street 1:1204 OVERMAN CIR APT C
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-4675
Practice Address - Country:US
Practice Address - Phone:252-455-6818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-05
Last Update Date:2021-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC000036344018Medicaid