Healthcare Provider Details

I. General information

NPI: 1588279459
Provider Name (Legal Business Name): VANESSA RENEE MIXON AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2020
Last Update Date: 09/08/2020
Certification Date: 09/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3783 WOOD CIR
COCOA FL
32926-4828
US

IV. Provider business mailing address

3783 WOOD CIR
COCOA FL
32926-4828
US

V. Phone/Fax

Practice location:
  • Phone: 321-961-6577
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN11005719
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: