Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | RN171399 | AZ |
Y | 207Q00000X | Family Doctor | RNP251475 | AZ |
N | 207QA0401X | Family Doctor - Addiction Medicine | RN171399 | AZ |
N | 207QA0401X | Family Doctor - Addiction Medicine | RNP251475 | AZ |
NPI | 1205432705 |
---|---|
Provider Name | Miss Renae Tylynne Mitchell |
First Address | Phoenix, AZ 85032-2481 |
Second Address | Phoenix, AZ 85032-2481 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/12/2020 |
Last Update Date | 23/12/2020 |