Healthcare Provider Details

I. General information

NPI: 1932999398
Provider Name (Legal Business Name): KRISTIE MICHELLE MIXON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2025
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10536 AUTO MALL PKWY
DIBERVILLE MS
39540-3742
US

IV. Provider business mailing address

207 N STEELE AVE
PICAYUNE MS
39466-4077
US

V. Phone/Fax

Practice location:
  • Phone: 985-774-1668
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: