Healthcare Provider Details

I. General information

NPI: 1770306656
Provider Name (Legal Business Name): TACQUORA LASHAE MIXON CMA,CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2024
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2882 CHURCH ST
EAST POINT GA
30344-3254
US

IV. Provider business mailing address

2882 CHURCH ST
EAST POINT GA
30344-3254
US

V. Phone/Fax

Practice location:
  • Phone: 404-692-8860
  • Fax:
Mailing address:
  • Phone: 404-692-8860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: