Provider Demographics
NPI:1871165860
Name:MIX, MICHELLE RENEE (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:MIX
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4724 NE SARATOGA CT
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64064-2110
Mailing Address - Country:US
Mailing Address - Phone:816-716-3938
Mailing Address - Fax:
Practice Address - Street 1:100 NE SAINT LUKES BLVD
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-6000
Practice Address - Country:US
Practice Address - Phone:816-347-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-11
Last Update Date:2021-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021026754363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care