Provider Demographics
NPI:1285172395
Name:MITCHELL, KELLEY M X (LPN)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:M
Last Name:MITCHELL
Suffix:X
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:PO BOX 321
Mailing Address - Street 2:210 NORTH MILLER STREET
Mailing Address - City:CARRIER MILLS
Mailing Address - State:IL
Mailing Address - Zip Code:62917
Mailing Address - Country:US
Mailing Address - Phone:618-713-2270
Mailing Address - Fax:
Practice Address - Street 1:210 MILLER STREET
Practice Address - Street 2:
Practice Address - City:CARRIER MILLS
Practice Address - State:IL
Practice Address - Zip Code:62917
Practice Address - Country:US
Practice Address - Phone:618-713-2270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043075812164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse