Provider Demographics
NPI:1750169538
Name:MITCHELL, KEITH WALLACE JR (RN)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:WALLACE
Last Name:MITCHELL
Suffix:JR
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:66 WALTER ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6234
Mailing Address - Country:US
Mailing Address - Phone:207-902-0990
Mailing Address - Fax:
Practice Address - Street 1:118 NORTHPORT AVE
Practice Address - Street 2:
Practice Address - City:BELFAST
Practice Address - State:ME
Practice Address - Zip Code:04915-6072
Practice Address - Country:US
Practice Address - Phone:207-505-4123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME68085163WP0808X, 163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health