Provider Demographics
NPI:1093325961
Name:MIXON, KARLIE INGRAM (DPT)
Entity Type:Individual
Prefix:
First Name:KARLIE
Middle Name:INGRAM
Last Name:MIXON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 MORNING GLORY RD
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:GA
Mailing Address - Zip Code:31092-4470
Mailing Address - Country:US
Mailing Address - Phone:229-938-3069
Mailing Address - Fax:
Practice Address - Street 1:1107 GREER ST
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-1920
Practice Address - Country:US
Practice Address - Phone:229-273-2445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist