Healthcare Provider Details

I. General information

NPI: 1659628634
Provider Name (Legal Business Name): PRISCILLA LYNN MIXON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2012
Last Update Date: 08/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SARNO RD STE 14
MELBOURNE FL
32935-4993
US

IV. Provider business mailing address

1157 SANDDUNE LN APT 106 1157 SANDDUNE LANE #106
MELBOURNE FL
32935-5236
US

V. Phone/Fax

Practice location:
  • Phone: 321-752-3111
  • Fax: 321-752-3114
Mailing address:
  • Phone: 321-806-6175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: