Provider Demographics
NPI:1295218774
Name:MIXON, LACEY BEARD (CRNP)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:BEARD
Last Name:MIXON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 MONROE ST STE 1600
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36104-3721
Mailing Address - Country:US
Mailing Address - Phone:334-206-9344
Mailing Address - Fax:334-206-3715
Practice Address - Street 1:1781 E COTTONWOOD RD
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-5309
Practice Address - Country:US
Practice Address - Phone:334-678-5851
Practice Address - Fax:334-678-2803
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-37700363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner