Provider Demographics
NPI:1689959942
Name:MITCHELL, MARY ROSE BALUNOS (ARNP)
Entity Type:Individual
Prefix:
First Name:MARY ROSE
Middle Name:BALUNOS
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:MARY ROSE
Other - Middle Name:PABUSTAN
Other - Last Name:BALUNOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, ARNP
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 TAMPA GENERAL CIR
Practice Address - Street 2:2ND FLOOR
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3603
Practice Address - Country:US
Practice Address - Phone:813-259-8700
Practice Address - Fax:813-250-2101
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9250094363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004224300Medicaid
FLY09A1OtherBLUE CROSS BLUE SHIELD
FLY09A1OtherBLUE CROSS BLUE SHIELD