Healthcare Provider Details

I. General information

NPI: 1013134121
Provider Name (Legal Business Name): LAURIE MIXTER MS, RD, HHP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15644 POMERADO RD SUITE 304
POWAY CA
92064-2400
US

IV. Provider business mailing address

15644 POMERADO RD SUITE 304
POWAY CA
92064-2400
US

V. Phone/Fax

Practice location:
  • Phone: 760-315-1555
  • Fax: 760-788-1659
Mailing address:
  • Phone: 760-315-1555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number887748
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberCMT 735
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: