Provider Demographics
NPI:1972772127
Name:MITCHELL, AMY S BOLTON TAYLOR (LAC)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:S BOLTON TAYLOR
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1738 SOLANO AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94707-2215
Mailing Address - Country:US
Mailing Address - Phone:510-558-0117
Mailing Address - Fax:510-558-8808
Practice Address - Street 1:1738 SOLANO AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94707-2215
Practice Address - Country:US
Practice Address - Phone:510-558-0117
Practice Address - Fax:510-558-8808
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-21
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 10749171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist