Healthcare Provider Details

I. General information

NPI: 1427703578
Provider Name (Legal Business Name): LISA MIX RN CCM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2022
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 454TH BLVD
HARRIS MN
55032-4000
US

IV. Provider business mailing address

1391 NW 136TH AVE
SUNRISE FL
33323-2800
US

V. Phone/Fax

Practice location:
  • Phone: 651-334-5671
  • Fax:
Mailing address:
  • Phone: 612-400-4652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number4241198
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number221730-30
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberR141093-2
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: