Provider Demographics
NPI:1053967059
Name:MITCHELL, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
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 1:106 MAPLE LN
Mailing Address - Street 2:
Mailing Address - City:PITTSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18640-2810
Mailing Address - Country:US
Mailing Address - Phone:570-239-1348
Mailing Address - Fax:
Practice Address - Street 1:609 LUZERNE ST
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18504-2626
Practice Address - Country:US
Practice Address - Phone:570-342-6411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP453728183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist