Basic Information
| Provider Information | |||||||||
| NPI: | 1326507195 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | WHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PROFESSIONAL DR | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620025068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184638500 | ||||||||
| FaxNumber: | 6184740130 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 PROFESSIONAL DR STE 150 | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620025070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184631181 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2019 | ||||||||
| LastUpdateDate: | 11/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 209019077 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
No ID Information.