Basic Information
Provider Information | |||||||||
NPI: | 1710117460 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MITCHELL | ||||||||
FirstName: | ERIN | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GRAY | ||||||||
OtherFirstName: | ERIN | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | FNP-BC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 200 HYGEIA DR | ||||||||
Address2: |   | ||||||||
City: | NEWARK | ||||||||
State: | DE | ||||||||
PostalCode: | 197132049 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3027331439 | ||||||||
FaxNumber: | 3027331888 | ||||||||
Practice Location | |||||||||
Address1: | 4755 OGLETOWN STANTON RD | ||||||||
Address2: | SUITE 1049 - NEUROVASCULAR ADMINISTRATION | ||||||||
City: | NEWARK | ||||||||
State: | DE | ||||||||
PostalCode: | 197180001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3027331439 | ||||||||
FaxNumber: | 3027331888 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/15/2009 | ||||||||
LastUpdateDate: | 11/17/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | LG-0000507 | DE | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 1710117460 | 05 | DE |   | MEDICAID |