Provider Demographics
NPI:1689057465
Name:MIXON, CONNIE ANN
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:ANN
Last Name:MIXON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:CONNIE
Other - Middle Name:ANN
Other - Last Name:BYRD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:990 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:VIDOR
Mailing Address - State:TX
Mailing Address - Zip Code:77662-4418
Mailing Address - Country:US
Mailing Address - Phone:281-312-9651
Mailing Address - Fax:
Practice Address - Street 1:990 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:VIDOR
Practice Address - State:TX
Practice Address - Zip Code:77662-4418
Practice Address - Country:US
Practice Address - Phone:281-312-9651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2016-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider