Provider Demographics
NPI:1598511032
Name:MITCHELL, BROOK
Entity type:Individual
Prefix:
First Name:BROOK
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 DIPLOMAT DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-3313
Mailing Address - Country:US
Mailing Address - Phone:252-515-4876
Mailing Address - Fax:
Practice Address - Street 1:2 RIVERSIDE CIR
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4950
Practice Address - Country:US
Practice Address - Phone:252-515-4876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program