Provider Demographics
NPI:1568811404
Name:NIX, KANETHA
Entity Type:Individual
Prefix:
First Name:KANETHA
Middle Name:
Last Name:NIX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 KILLEARN CENTER BLVD APT D83
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-3568
Mailing Address - Country:US
Mailing Address - Phone:850-363-5832
Mailing Address - Fax:
Practice Address - Street 1:2305 KILLEARN CENTER BLVD APT D83
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32309-3568
Practice Address - Country:US
Practice Address - Phone:850-363-5832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical