Provider Demographics
NPI:1205381043
Name:MIXCO, ALICIA (LVN)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:MIXCO
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15190 LIME ST
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-3819
Mailing Address - Country:US
Mailing Address - Phone:909-855-3298
Mailing Address - Fax:909-795-2325
Practice Address - Street 1:15190 LIME ST
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-3819
Practice Address - Country:US
Practice Address - Phone:909-855-3298
Practice Address - Fax:909-795-2325
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA218053164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse