Provider Demographics
NPI:1730707860
Name:MITCHELL, MARYLYN (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:MARYLYN
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 BROKEN SHOE TRL
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-0085
Mailing Address - Country:US
Mailing Address - Phone:254-228-6062
Mailing Address - Fax:
Practice Address - Street 1:2120 BROKEN SHOE TRL
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-0085
Practice Address - Country:US
Practice Address - Phone:254-228-6062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1000062363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1000062OtherTEXAS NP LICENSE NUMBER