Provider Demographics
NPI:1316284011
Name:MITCHELL, NICOLE SHONTREASE (CRNA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:SHONTREASE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 N OLIVE AVE
Mailing Address - Street 2:STE 203
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-3520
Mailing Address - Country:US
Mailing Address - Phone:217-788-3755
Mailing Address - Fax:217-788-7071
Practice Address - Street 1:701 N 1ST ST
Practice Address - Street 2:ANESTHESIA DEPT
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62781-0001
Practice Address - Country:US
Practice Address - Phone:217-788-3755
Practice Address - Fax:217-788-7071
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9402261367500000X
IL209010168367500000X
GACRNA000564367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
87597OtherANCC CERTIFICATION