Provider Demographics
NPI:1902807720
Name:MIXON, GINA H (RD)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:H
Last Name:MIXON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 PLACE ROAD
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39437
Mailing Address - Country:US
Mailing Address - Phone:601-426-4086
Mailing Address - Fax:601-426-4417
Practice Address - Street 1:1220 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4355
Practice Address - Country:US
Practice Address - Phone:601-426-4086
Practice Address - Fax:601-426-4417
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD0722133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06023396Medicaid