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General NPI Number Information
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NPI Number | 1053635755
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Entity Type | Individual
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Provider Name | DEITRA T MIXER
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Gender | Female
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Dates
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Enumeration Date | 03/24/2010
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Last Update Date | 03/24/2010
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Provider Practice Location Address
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Address Line | 8221 LENOX CREEKSIDE DR UNIT 7
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City | CANE RIDGE
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State | TN
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Zip | 37013-4657
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Country | US
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Telephone | 615-417-3321
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Fax |
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Provider Business Mailing Address
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Address Line | 8221 LENOX CREEKSIDE DR UNIT 7
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City | CANE RIDGE
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State | TN
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Zip | 37013-4656
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Country | US
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Telephone | 615-417-3321
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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