Provider Demographics
NPI:1033823000
Name:MIXON, JOLIE GARDNER (APRN)
Entity Type:Individual
Prefix:MRS
First Name:JOLIE
Middle Name:GARDNER
Last Name:MIXON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 BOTTES AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70592-5184
Mailing Address - Country:US
Mailing Address - Phone:337-349-4614
Mailing Address - Fax:
Practice Address - Street 1:4801 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6917
Practice Address - Country:US
Practice Address - Phone:337-470-2911
Practice Address - Fax:337-470-2695
Is Sole Proprietor?:No
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA229060363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily