=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205205358
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELBY ELIZABETH MIXELL PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2015
-----------------------------------------------------
Last Update Date | 03/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 E APPLE STREET SUITE 3300
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-208-8394
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1005 DERRINGER DRIVE
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-694-8140
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 50.004469
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------