Provider Demographics
NPI:1013134121
Name:MIXTER, LAURIE (MS, RD, HHP)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:MIXTER
Suffix:
Gender:F
Credentials:MS, RD, HHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15644 POMERADO RD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2400
Mailing Address - Country:US
Mailing Address - Phone:760-315-1555
Mailing Address - Fax:
Practice Address - Street 1:15644 POMERADO RD
Practice Address - Street 2:SUITE 304
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2400
Practice Address - Country:US
Practice Address - Phone:760-315-1555
Practice Address - Fax:760-788-1659
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA887748133V00000X
CACMT 735225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered