Provider Demographics
NPI:1053635755
Name:MIXER, DEITRA T
Entity Type:Individual
Prefix:
First Name:DEITRA
Middle Name:T
Last Name:MIXER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8221 LENOX CREEKSIDE DR
Mailing Address - Street 2:UNIT 7
Mailing Address - City:CANE RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37013-4656
Mailing Address - Country:US
Mailing Address - Phone:615-417-3321
Mailing Address - Fax:
Practice Address - Street 1:8221 LENOX CREEKSIDE DR UNIT 7
Practice Address - Street 2:
Practice Address - City:CANE RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37013-4657
Practice Address - Country:US
Practice Address - Phone:615-417-3321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist