Healthcare Provider Details

I. General information

NPI: 1558712570
Provider Name (Legal Business Name): GINA MARIE MIXON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2016
Last Update Date: 06/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16033 DOCTORS BLVD
HAMMOND LA
70403-1479
US

IV. Provider business mailing address

16033 DOCTORS BLVD
HAMMOND LA
70403-1479
US

V. Phone/Fax

Practice location:
  • Phone: 985-974-9278
  • Fax:
Mailing address:
  • Phone: 985-974-9278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number08915
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: