Healthcare Provider Details

I. General information

NPI: 1295216497
Provider Name (Legal Business Name): ALIYAH MIXON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2018
Last Update Date: 08/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E UNIVERSITY
MAGNOLIA AR
71753-2181
US

IV. Provider business mailing address

915 WHITE ST
MCCOMB MS
39648-2953
US

V. Phone/Fax

Practice location:
  • Phone: 870-235-4142
  • Fax:
Mailing address:
  • Phone: 601-395-2687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: