Provider Demographics
NPI:1265517601
Name:MITCHELL, SALLY ANN (CAA)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:ANN
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FPHO MANAGED CARE
Mailing Address - Street 2:1102 WEST 32ND STREET
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:417-347-5033
Practice Address - Street 1:1102 W 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3503
Practice Address - Country:US
Practice Address - Phone:417-347-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003351367H00000X
IN75000008A367H00000X
MO2024023954367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC100000298BMedicaid
S92619Medicare UPIN
GA97WCCQLMedicare ID - Type Unspecified