Healthcare Provider Details

I. General information

NPI: 1255965273
Provider Name (Legal Business Name): KELLYE MIXSON MSN, APRN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2020
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 PARKSTONE HEIGHTS DR STE 360
AUSTIN TX
78746-7482
US

IV. Provider business mailing address

4101 PARKSTONE HEIGHTS DR STE 360
AUSTIN TX
78746-7482
US

V. Phone/Fax

Practice location:
  • Phone: 940-781-9549
  • Fax:
Mailing address:
  • Phone: 940-781-9549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number145313
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: