Healthcare Provider Details

I. General information

NPI: 1255014635
Provider Name (Legal Business Name): TYCHELLE MIXON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2023
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 WOODLAND AVE # F9
CLEVELAND OH
44104-3087
US

IV. Provider business mailing address

3265 E 147TH ST APT 11
CLEVELAND OH
44120-4100
US

V. Phone/Fax

Practice location:
  • Phone: 216-240-0498
  • Fax:
Mailing address:
  • Phone: 216-609-7152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberUA880623
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: