Basic Information
| Provider Information | |||||||||
| NPI: | 1881962595 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5472 BASTIAN BLVD | ||||||||
| Address2: | |||||||||
| City: | SOUTH BELOIT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610809226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155250213 | ||||||||
| FaxNumber: | 8155250213 | ||||||||
| Practice Location | |||||||||
| Address1: | 1221 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611042231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159721000 | ||||||||
| FaxNumber: | 8159721092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2011 | ||||||||
| LastUpdateDate: | 12/08/2011 | ||||||||
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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 | 363LP0808X | 209007407 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 209007407 | 01 | IL | APN LICENSE | OTHER |