Healthcare Provider Details

I. General information

NPI: 1205205358
Provider Name (Legal Business Name): KELBY ELIZABETH MIXELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELBY SNORF

II. Dates (important events)

Enumeration Date: 09/18/2015
Last Update Date: 03/29/2024
Certification Date: 03/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 E APPLE STREET SUITE 3300
DAYTON OH
45409
US

IV. Provider business mailing address

1005 DERRINGER DRIVE
ENGLEWOOD OH
45322
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-8394
  • Fax:
Mailing address:
  • Phone: 937-694-8140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.004469
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: