Provider Demographics
NPI:1730510207
Name:MIXSON, ANAIS (ATC)
Entity type:Individual
Prefix:
First Name:ANAIS
Middle Name:
Last Name:MIXSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4438 YORKTOWN PL
Mailing Address - Street 2:
Mailing Address - City:MAYS LANDING
Mailing Address - State:NJ
Mailing Address - Zip Code:08330-2703
Mailing Address - Country:US
Mailing Address - Phone:732-673-9907
Mailing Address - Fax:
Practice Address - Street 1:4438 YORKTOWN PL
Practice Address - Street 2:
Practice Address - City:MAYS LANDING
Practice Address - State:NJ
Practice Address - Zip Code:08330
Practice Address - Country:US
Practice Address - Phone:732-673-9907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT001510002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer