Provider Demographics
NPI:1104552421
Name:MITCHELL, MIRANDA JO (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:JO
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
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Mailing Address - Street 1:330 N WABASH AVE STE G-20
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2605
Mailing Address - Country:US
Mailing Address - Phone:765-660-7600
Mailing Address - Fax:765-651-7313
Practice Address - Street 1:1130 N BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2536
Practice Address - Country:US
Practice Address - Phone:765-660-7480
Practice Address - Fax:765-662-1259
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN28235947A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner