Provider Demographics
NPI:1457684045
Name:HIXSON, ANGELINE WYNNE (OD)
Entity Type:Individual
Prefix:DR
First Name:ANGELINE
Middle Name:WYNNE
Last Name:HIXSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:ANGELINE
Other - Middle Name:WYNNE
Other - Last Name:MOUTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1100 THORNTON RD
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-2616
Mailing Address - Country:US
Mailing Address - Phone:770-819-4981
Mailing Address - Fax:770-819-9039
Practice Address - Street 1:1100 THORNTON RD
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-2616
Practice Address - Country:US
Practice Address - Phone:404-819-9039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-14
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4475152W00000X
GAOPT 002582152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist