Healthcare Provider Details

I. General information

NPI: 1376121426
Provider Name (Legal Business Name): KELLY PRINCE MIXON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 11/13/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 MIMOSA DR
THOMASVILLE GA
31792-6605
US

IV. Provider business mailing address

116 MIMOSA DR
THOMASVILLE GA
31792-6605
US

V. Phone/Fax

Practice location:
  • Phone: 229-584-5570
  • Fax: 229-551-8697
Mailing address:
  • Phone: 229-584-5570
  • Fax: 229-551-8697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN254729
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: