Provider Demographics
NPI:1205521028
Name:MITCHELL, ANGELA GAIL (FNP-C)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:GAIL
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 315
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:901-227-8693
Mailing Address - Fax:
Practice Address - Street 1:401 SOUTHCREST CIR STE 104
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-6712
Practice Address - Country:US
Practice Address - Phone:901-763-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-07
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904119363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily