Healthcare Provider Details

I. General information

NPI: 1487256426
Provider Name (Legal Business Name): KRISTEN MIX DNP, AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2020
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15855 19 MILE RD
CLINTON TOWNSHIP MI
48038-3504
US

IV. Provider business mailing address

950 SHERRY DR
LAKE ORION MI
48362-2870
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-2300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number4704285817
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704285817
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: