Healthcare Provider Details

I. General information

NPI: 1134387053
Provider Name (Legal Business Name): SANDRA LEE MIXSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2008
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8422 SUN DR
PORT RICHEY FL
34668-3339
US

IV. Provider business mailing address

8422 SUN DR
PORT RICHEY FL
34668-3339
US

V. Phone/Fax

Practice location:
  • Phone: 727-237-1570
  • Fax: 727-862-0747
Mailing address:
  • Phone: 727-237-1570
  • Fax: 727-862-0747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN3255162
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: