Provider Demographics
NPI:1720885049
Name:MITCHELL, STACY JO
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:JO
Last Name:MITCHELL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 NW JACKSON DR
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-8854
Mailing Address - Country:US
Mailing Address - Phone:309-269-6396
Mailing Address - Fax:
Practice Address - Street 1:604 NW JACKSON DR
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-8854
Practice Address - Country:US
Practice Address - Phone:309-269-6396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01627133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered