Provider Demographics
NPI:1831881960
Name:MITCHELL, WILLIE M III
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:M
Last Name:MITCHELL
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28999 OLD TOWN FRONT ST STE 104
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-2842
Mailing Address - Country:US
Mailing Address - Phone:951-261-8392
Mailing Address - Fax:
Practice Address - Street 1:28999 OLD TOWN FRONT ST STE 104
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-2842
Practice Address - Country:US
Practice Address - Phone:951-261-8392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA700399164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse