Healthcare Provider Details

I. General information

NPI: 1467175430
Provider Name (Legal Business Name): MRS. DENISE M MIXON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2022
Last Update Date: 09/23/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6007 REGAL CREST DR
CHESTERFIELD VA
23832-7935
US

IV. Provider business mailing address

6007 REGAL CREST DR
CHESTERFIELD VA
23832-7935
US

V. Phone/Fax

Practice location:
  • Phone: 804-387-9058
  • Fax:
Mailing address:
  • Phone: 804-387-9058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: