Provider Demographics
NPI:1205205358
Name:MIXELL, KELBY ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:KELBY
Middle Name:ELIZABETH
Last Name:MIXELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELBY
Other - Middle Name:
Other - Last Name:SNORF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1005 DERRINGER DRIVE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322
Mailing Address - Country:US
Mailing Address - Phone:937-694-8140
Mailing Address - Fax:
Practice Address - Street 1:30 E APPLE STREET
Practice Address - Street 2:SUITE 3300
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409
Practice Address - Country:US
Practice Address - Phone:937-208-8394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-18
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004469363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1125596OtherNATIONAL CERTIFICATION OF PHYSICIAN ASSISTANT
OH50.004469OtherOHIO CERTIFICATION TO PRACTICE- PHYSICIAN ASSISTANT
OH0144502Medicaid
OH0144502Medicaid