Basic Information
| Provider Information | |||||||||
| NPI: | 1982853149 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 699 E POPLAR AVE | ||||||||
| Address2: | |||||||||
| City: | SELMER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383751828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314343401 | ||||||||
| FaxNumber: | 7314343403 | ||||||||
| Practice Location | |||||||||
| Address1: | 270 E COURT AVE | ||||||||
| Address2: | |||||||||
| City: | SELMER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383752304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316457932 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2008 | ||||||||
| LastUpdateDate: | 02/21/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2820 | TN | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.