Provider Demographics
NPI:1740844299
Name:MIXSON, TAMATHA BOWERS (RN-BSN)
Entity type:Individual
Prefix:MRS
First Name:TAMATHA
Middle Name:BOWERS
Last Name:MIXSON
Suffix:
Gender:F
Credentials:RN-BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:768 MAIN ST E
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:SC
Mailing Address - Zip Code:29827-8756
Mailing Address - Country:US
Mailing Address - Phone:803-686-1524
Mailing Address - Fax:
Practice Address - Street 1:768 MAIN ST E
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:SC
Practice Address - Zip Code:29827-8756
Practice Address - Country:US
Practice Address - Phone:803-686-1524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC235024163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health