Healthcare Provider Details

I. General information

NPI: 1467647115
Provider Name (Legal Business Name): SUSAN M. MIX FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 09/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 GOLF VIEW DRIVE SUITE #200
MEDFORD OR
97504
US

IV. Provider business mailing address

760 GOLF VIEW DRIVE SUITE #200
MEDFORD OR
97504
US

V. Phone/Fax

Practice location:
  • Phone: 541-618-4400
  • Fax: 541-618-4406
Mailing address:
  • Phone: 541-618-4400
  • Fax: 541-618-4406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200750116NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: