Basic Information
| Provider Information | |||||||||
| NPI: | 1073745808 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | DORIS | ||||||||
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| Credential: | PA-C, M.S., RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1750 E GRAND RIVER AVE | ||||||||
| Address2: | STE. 103 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488234958 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 N PARK ST | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490073731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693737488 | ||||||||
| FaxNumber: | 2693737478 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2009 | ||||||||
| LastUpdateDate: | 07/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 363AM0700X | 5601006860 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 5601006860 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.