1194389874 NPI number — MEGAN DANIELLE NIX

Table of content: MEGAN DANIELLE NIX (NPI 1194389874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194389874 NPI number — MEGAN DANIELLE NIX

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NIX
Provider First Name:
MEGAN
Provider Middle Name:
DANIELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194389874
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3525 US HIGHWAY 17
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLEMING ISLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32003-7122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-297-0054
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12276 SAN JOSE BLVD STE 508
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32223-8618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-886-3228
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/27/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106E00000X , with the licence number: 0-22-14085 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: BCABA , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".