Provider Demographics
NPI:1689451684
Name:MITCHELL, ANDREA ANDERSON
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:ANDERSON
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 1:6157 CEDAR HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-5177
Mailing Address - Country:US
Mailing Address - Phone:904-808-5634
Mailing Address - Fax:
Practice Address - Street 1:3533 OLEANDER ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-1732
Practice Address - Country:US
Practice Address - Phone:904-808-5634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL217402374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL83-3766776Medicaid