Provider Demographics
NPI:1598511230
Name:MITCHELL, SHANTESE SAYANA
Entity type:Individual
Prefix:
First Name:SHANTESE
Middle Name:SAYANA
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 1:1810 WESLEY CT
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60431-8561
Mailing Address - Country:US
Mailing Address - Phone:331-333-9377
Mailing Address - Fax:
Practice Address - Street 1:1810 WESLEY CT
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60431-8561
Practice Address - Country:US
Practice Address - Phone:331-333-9377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X, 374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program