Provider Demographics
NPI:1255014635
Name:MIXON, TYCHELLE
Entity type:Individual
Prefix:
First Name:TYCHELLE
Middle Name:
Last Name:MIXON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3265 E 147TH ST APT 11
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-4100
Mailing Address - Country:US
Mailing Address - Phone:216-609-7152
Mailing Address - Fax:
Practice Address - Street 1:7600 WOODLAND AVE # F9
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104-3087
Practice Address - Country:US
Practice Address - Phone:216-240-0498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHUA880623163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice