Healthcare Provider Details

I. General information

NPI: 1922562479
Provider Name (Legal Business Name): LAUREN E MIX CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2019
Last Update Date: 11/05/2021
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 BURLEYSON RD
DALTON GA
30720-3181
US

IV. Provider business mailing address

105 JW PLAZA DR SE STE 1
CALHOUN GA
30701-1503
US

V. Phone/Fax

Practice location:
  • Phone: 706-278-4640
  • Fax: 706-275-6599
Mailing address:
  • Phone: 706-278-4640
  • Fax: 706-275-6599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number283465
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number53980
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: