Provider Demographics
NPI:1720170681
Name:MITCHELL, KATHI LYN (LVN)
Entity Type:Individual
Prefix:MS
First Name:KATHI
Middle Name:LYN
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-0027
Mailing Address - Country:US
Mailing Address - Phone:707-725-9726
Mailing Address - Fax:
Practice Address - Street 1:3547 RENNER DR
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-3106
Practice Address - Country:US
Practice Address - Phone:707-725-9726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 198434164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARVN003510Medicare ID - Type Unspecified
CAEPS015200Medicare ID - Type Unspecified