Provider Demographics
NPI:1841896263
Name:MIXON, SUSAN MICHELLE
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MICHELLE
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 1:3285 FERGUSON ST SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-6143
Mailing Address - Country:US
Mailing Address - Phone:360-943-1907
Mailing Address - Fax:
Practice Address - Street 1:3285 FERGUSON ST SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512
Practice Address - Country:US
Practice Address - Phone:360-280-9889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP00045866164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse