Basic Information
| Provider Information | |||||||||
| NPI: | 1164067286 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | MARILYN | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 734 N HIGHLAND AVE NE APT 2 | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303064501 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 95 COLLIER RD NW STE 2055 | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046055699 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2019 | ||||||||
| LastUpdateDate: | 03/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 9444 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.