Healthcare Provider Details

I. General information

NPI: 1588803928
Provider Name (Legal Business Name): KEVIN O MIXON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2009
Last Update Date: 12/29/2022
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15770 PAUL VEGA MD DR STE 202
HAMMOND LA
70403-1475
US

IV. Provider business mailing address

PO BOX 3087
HAMMOND LA
70404-3087
US

V. Phone/Fax

Practice location:
  • Phone: 985-230-7495
  • Fax: 985-230-7496
Mailing address:
  • Phone: 985-230-7495
  • Fax: 985-230-1861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP03979
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: