Provider Demographics
NPI:1396999439
Name:MITCHELL, SHELLY AMANDA (RD)
Entity type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:AMANDA
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:SHELLY
Other - Middle Name:AMANDA
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:4 BAKER DR
Mailing Address - Street 2:
Mailing Address - City:BELLA VISTA
Mailing Address - State:AR
Mailing Address - Zip Code:72715-6611
Mailing Address - Country:US
Mailing Address - Phone:479-855-0121
Mailing Address - Fax:
Practice Address - Street 1:3215 N NORTHHILLS BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4424
Practice Address - Country:US
Practice Address - Phone:479-463-4121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT80630133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered