Provider Demographics
NPI:1790950103
Name:MITCHELL, SANDRA KAY
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:KAY
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 1:324 MULBERRY AVE W
Mailing Address - Street 2:
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-2813
Mailing Address - Country:US
Mailing Address - Phone:807-208-5444
Mailing Address - Fax:
Practice Address - Street 1:324 MULBERRY AVE W
Practice Address - Street 2:
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396-2813
Practice Address - Country:US
Practice Address - Phone:807-208-5444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR166087783Medicaid