Healthcare Provider Details

I. General information

NPI: 1386610608
Provider Name (Legal Business Name): STEPHEN G MIXON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 03/31/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 N HWY 190
COVINGTON LA
70433-5158
US

IV. Provider business mailing address

PO BOX 3370
COVINGTON LA
70434-3370
US

V. Phone/Fax

Practice location:
  • Phone: 985-400-5988
  • Fax: 985-867-3644
Mailing address:
  • Phone: 985-400-5988
  • Fax: 985-867-3644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN073581 AP03978
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: