Provider Demographics
NPI:1194057810
Name:MITCHELL, GINA M (LPN)
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:M
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 BELLVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11719-9705
Mailing Address - Country:US
Mailing Address - Phone:631-286-3892
Mailing Address - Fax:
Practice Address - Street 1:27 BELLVIEW AVE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11719-9705
Practice Address - Country:US
Practice Address - Phone:631-286-3892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY245874-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse