Healthcare Provider Details

I. General information

NPI: 1316450661
Provider Name (Legal Business Name): LISA PAIGE MIZELLE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2017
Last Update Date: 11/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2604 HIGHWAY 31 S
DECATUR AL
35603-1506
US

IV. Provider business mailing address

2604 HIGHWAY 31 S STE 100
DECATUR AL
35603-1506
US

V. Phone/Fax

Practice location:
  • Phone: 256-445-3100
  • Fax:
Mailing address:
  • Phone: 256-445-3100
  • Fax: 256-445-3104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-073714
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: