Healthcare Provider Details

I. General information

NPI: 1295218774
Provider Name (Legal Business Name): LACEY BEARD MIXON CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1781 E COTTONWOOD RD
DOTHAN AL
36301-5309
US

IV. Provider business mailing address

201 MONROE ST STE 1600
MONTGOMERY AL
36104-3721
US

V. Phone/Fax

Practice location:
  • Phone: 334-678-5851
  • Fax: 334-678-2803
Mailing address:
  • Phone: 334-206-9344
  • Fax: 334-206-3715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-37700
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: