Provider Demographics
NPI:1639409204
Name:MIX, DEBORAH JEAN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:JEAN
Last Name:MIX
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6176 OATKA RD
Mailing Address - Street 2:POB# 306
Mailing Address - City:PERRY
Mailing Address - State:NY
Mailing Address - Zip Code:14530-9548
Mailing Address - Country:US
Mailing Address - Phone:585-237-2812
Mailing Address - Fax:
Practice Address - Street 1:6176 OATKA RD
Practice Address - Street 2:POB# 306
Practice Address - City:PERRY
Practice Address - State:NY
Practice Address - Zip Code:14530-9548
Practice Address - Country:US
Practice Address - Phone:585-237-2812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-05
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY097737164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse