Provider Demographics
NPI:1710181714
Name:MIXON, KEELY NICOLE (PA)
Entity Type:Individual
Prefix:MISS
First Name:KEELY
Middle Name:NICOLE
Last Name:MIXON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2699
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-416-7619
Mailing Address - Fax:
Practice Address - Street 1:5151 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8721
Practice Address - Country:US
Practice Address - Phone:850-416-7619
Practice Address - Fax:850-416-7753
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110923363A00000X
ALPA.1523363A00000X
LAPA.200255363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1380709Medicaid
LA5F973PD53Medicare Oscar/Certification