Provider Demographics
NPI:1871559179
Name:MIX, LISA A (CNM)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:MIX
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:900 S DIXIE DR
Mailing Address - Street 2:SUITE 40
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377-2657
Mailing Address - Country:US
Mailing Address - Phone:937-890-6644
Mailing Address - Fax:937-890-1726
Practice Address - Street 1:900 S DIXIE DR
Practice Address - Street 2:SUITE 40
Practice Address - City:VANDALIA
Practice Address - State:OH
Practice Address - Zip Code:45377-2657
Practice Address - Country:US
Practice Address - Phone:937-890-6644
Practice Address - Fax:937-890-1726
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OHNM05540367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2339704Medicaid
OH2339704Medicaid
OHNM04051Medicare PIN
OHNM02399Medicare PIN