Provider Demographics
NPI:1861642613
Name:MITCHELL-EJIMAKOR, PAULINE ANNETT
Entity Type:Individual
Prefix:
First Name:PAULINE
Middle Name:ANNETT
Last Name:MITCHELL-EJIMAKOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PAULINE
Other - Middle Name:ANNETT
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1300 MERCANTILE LN
Mailing Address - Street 2:SUITE 138E
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5327
Mailing Address - Country:US
Mailing Address - Phone:240-667-1594
Mailing Address - Fax:240-667-1596
Practice Address - Street 1:1300 MERCANTILE LN
Practice Address - Street 2:SUITE 138 E
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5327
Practice Address - Country:US
Practice Address - Phone:240-667-1594
Practice Address - Fax:240-667-1596
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-29
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR2683332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD6376150001Medicare NSC