Healthcare Provider Details

I. General information

NPI: 1679051239
Provider Name (Legal Business Name): NANCY MARIE MIXON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2018
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 DILLON DR
PUEBLO CO
81008-2113
US

IV. Provider business mailing address

1046 S MESCAL DR
PUEBLO WEST CO
81007-1958
US

V. Phone/Fax

Practice location:
  • Phone: 719-543-8348
  • Fax:
Mailing address:
  • Phone: 720-227-3846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4060
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0022933
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: