Provider Demographics
NPI:1992512479
Name:MITCHUM, MARK TIMOTHY
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:TIMOTHY
Last Name:MITCHUM
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 1:311 HILLVIEW DR
Mailing Address - Street 2:
Mailing Address - City:HORSE CAVE
Mailing Address - State:KY
Mailing Address - Zip Code:42749-8048
Mailing Address - Country:US
Mailing Address - Phone:270-540-1080
Mailing Address - Fax:
Practice Address - Street 1:2022 BATTERY PARK DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:KY
Practice Address - Zip Code:42740
Practice Address - Country:US
Practice Address - Phone:859-314-3670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1112028163WX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0106XNursing Service ProvidersRegistered NurseOccupational Health