Healthcare Provider Details

I. General information

NPI: 1972326684
Provider Name (Legal Business Name): CORRYNN LEA MIX FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2024
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2130 W SYCAMORE ST STE 260
KOKOMO IN
46901-6460
US

IV. Provider business mailing address

2130 W SYCAMORE ST STE 260
KOKOMO IN
46901-6460
US

V. Phone/Fax

Practice location:
  • Phone: 765-236-8457
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number71016062A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: