Provider Demographics
NPI:1891964243
Name:MIXON, DETRESE DENESE (CNA,CMA)
Entity Type:Individual
Prefix:MRS
First Name:DETRESE
Middle Name:DENESE
Last Name:MIXON
Suffix:
Gender:F
Credentials:CNA,CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1936 MEHARRY AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-2622
Mailing Address - Country:US
Mailing Address - Phone:904-766-5815
Mailing Address - Fax:
Practice Address - Street 1:1936 MEHARRY AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-2622
Practice Address - Country:US
Practice Address - Phone:904-766-5815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-29
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA 112950172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker