Healthcare Provider Details

I. General information

NPI: 1912304692
Provider Name (Legal Business Name): KELLY MIXON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2014
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 N IRBY ST
FLORENCE SC
29501-2621
US

IV. Provider business mailing address

1119 N IRBY ST
FLORENCE SC
29501-2621
US

V. Phone/Fax

Practice location:
  • Phone: 843-664-8162
  • Fax: 843-664-8178
Mailing address:
  • Phone: 843-664-8162
  • Fax: 843-664-8178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number78085
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: