Provider Demographics
NPI:1598219917
Name:MIXSON, MELISSA ANN (PTA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:MIXSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4280 BISCAYNE DR
Mailing Address - Street 2:
Mailing Address - City:HERNANDO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34607-3003
Mailing Address - Country:US
Mailing Address - Phone:352-442-8358
Mailing Address - Fax:
Practice Address - Street 1:1445 HOWELL AVE
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-1502
Practice Address - Country:US
Practice Address - Phone:352-799-1451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA26728225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant