Provider Demographics
NPI:1487276010
Name:MCINTOSH, DIXIE LORAINE (NP)
Entity type:Individual
Prefix:
First Name:DIXIE
Middle Name:LORAINE
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 925
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-0925
Mailing Address - Country:US
Mailing Address - Phone:706-724-8611
Mailing Address - Fax:
Practice Address - Street 1:1348 WALTON WAY STE 5100
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-5108
Practice Address - Country:US
Practice Address - Phone:706-724-8611
Practice Address - Fax:706-724-6202
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA150973363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner