Healthcare Provider Details

I. General information

NPI: 1104287424
Provider Name (Legal Business Name): ASHLEIGH MIXON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2016
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E BRADY ST
MILWAUKEE WI
53202-1615
US

IV. Provider business mailing address

1400 E BRADY ST
MILWAUKEE WI
53202-1615
US

V. Phone/Fax

Practice location:
  • Phone: 414-272-2171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number174540-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6863-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: