Provider Demographics
NPI:1548010697
Name:MITCHELL, TRACY LYNETT
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNETT
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:PO BOX 1170
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92556-1170
Mailing Address - Country:US
Mailing Address - Phone:951-653-6958
Mailing Address - Fax:
Practice Address - Street 1:22365 BARTON RD STE 302
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5078
Practice Address - Country:US
Practice Address - Phone:951-653-6958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-22
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist