Provider Demographics
NPI:1568294551
Name:MITCHELL, AVA ROSE
Entity type:Individual
Prefix:
First Name:AVA
Middle Name:ROSE
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 1:1223 N HAVEN DR APT 403
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-1010
Mailing Address - Country:US
Mailing Address - Phone:501-303-7898
Mailing Address - Fax:
Practice Address - Street 1:105 S BLAIR ST
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-4410
Practice Address - Country:US
Practice Address - Phone:479-259-2339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-17
Last Update Date:2024-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR516529224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant