Provider Demographics
NPI:1326319013
Name:MIX, MICHELLE S (FNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:S
Last Name:MIX
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:SANDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:7320 SHALLOWFORD RD STE B
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2626
Mailing Address - Country:US
Mailing Address - Phone:423-648-6483
Mailing Address - Fax:423-648-6497
Practice Address - Street 1:7320 SHALLOWFORD RD STE B
Practice Address - Street 2:ATTN: PROVIDER ENROLLMENT
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-2626
Practice Address - Country:US
Practice Address - Phone:423-648-6483
Practice Address - Fax:423-648-6497
Is Sole Proprietor?:No
Enumeration Date:2012-01-26
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 204496-7363LF0000X
TN19827363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily