Healthcare Provider Details

I. General information

NPI: 1083339121
Provider Name (Legal Business Name): MIZELL HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2022
Last Update Date: 02/14/2023
Certification Date: 02/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1962 SPRING HILL AVE
MOBILE AL
36607-2304
US

IV. Provider business mailing address

PO BOX 787
GRAND BAY AL
36541-0787
US

V. Phone/Fax

Practice location:
  • Phone: 251-802-3595
  • Fax:
Mailing address:
  • Phone: 251-802-3595
  • Fax: 228-896-7174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. BABETTE JACKSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 251-802-3595