Provider Demographics
NPI:1306652268
Name:MITCHELL, AUDREY LEE
Entity type:Individual
Prefix:
First Name:AUDREY LEE
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10137 VIA PESCADERO
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-2742
Mailing Address - Country:US
Mailing Address - Phone:951-660-1431
Mailing Address - Fax:
Practice Address - Street 1:27300 IRIS AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-4802
Practice Address - Country:US
Practice Address - Phone:951-660-1431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86006688133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered