=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154907897
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. KIMBERLY MIX
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2021
-----------------------------------------------------
Last Update Date | 03/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10151 DEERWOOD PARK BLVD STE 250
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32256-0566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-533-4783
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8450 GATE PKWY W UNIT 1330
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32216-1072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-533-4783
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------