Healthcare Provider Details

I. General information

NPI: 1730510207
Provider Name (Legal Business Name): ANAIS MIXSON ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2013
Last Update Date: 12/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4438 YORKTOWN PL
MAYS LANDING NJ
08330
US

IV. Provider business mailing address

4438 YORKTOWN PL
MAYS LANDING NJ
08330-2703
US

V. Phone/Fax

Practice location:
  • Phone: 732-673-9907
  • Fax:
Mailing address:
  • Phone: 732-673-9907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00151000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: