Healthcare Provider Details

I. General information

NPI: 1053635755
Provider Name (Legal Business Name): DEITRA T MIXER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2010
Last Update Date: 03/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8221 LENOX CREEKSIDE DR UNIT 7
CANE RIDGE TN
37013-4657
US

IV. Provider business mailing address

8221 LENOX CREEKSIDE DR UNIT 7
CANE RIDGE TN
37013-4656
US

V. Phone/Fax

Practice location:
  • Phone: 615-417-3321
  • Fax:
Mailing address:
  • Phone: 615-417-3321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: