Provider Demographics
NPI:1538034434
Name:MITCHAM, JEDONNE
Entity type:Individual
Prefix:
First Name:JEDONNE
Middle Name:
Last Name:MITCHAM
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 1:245 HAGERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-5580
Mailing Address - Country:US
Mailing Address - Phone:201-560-3273
Mailing Address - Fax:
Practice Address - Street 1:245 HAGERMAN AVE
Practice Address - Street 2:
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-5580
Practice Address - Country:US
Practice Address - Phone:201-560-3273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-09
Last Update Date:2025-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY353444164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse