Provider Demographics
NPI:1770306656
Name:MIXON, TACQUORA LASHAE (CMA,CNA)
Entity type:Individual
Prefix:
First Name:TACQUORA
Middle Name:LASHAE
Last Name:MIXON
Suffix:
Gender:F
Credentials:CMA,CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2882 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-3254
Mailing Address - Country:US
Mailing Address - Phone:404-692-8860
Mailing Address - Fax:
Practice Address - Street 1:2882 CHURCH ST
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3254
Practice Address - Country:US
Practice Address - Phone:404-692-8860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No253Z00000XAgenciesIn Home Supportive Care