Healthcare Provider Details

I. General information

NPI: 1972117562
Provider Name (Legal Business Name): DYLAN KEITH MIXSON FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2020
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 BREEDLOVE DR STE A
MONROE GA
30655-2054
US

IV. Provider business mailing address

18 FERN PARK LN
DAWSONVILLE GA
30534-8417
US

V. Phone/Fax

Practice location:
  • Phone: 888-772-0076
  • Fax: 770-751-8014
Mailing address:
  • Phone: 706-248-0993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN248478
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: