Healthcare Provider Details

I. General information

NPI: 1710480017
Provider Name (Legal Business Name): TRACEY LYNN MIZE NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 03/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5440 THORNBURN ST
LOS ANGELES CA
90045-2273
US

IV. Provider business mailing address

PO BOX 91854
LOS ANGELES CA
90009-1854
US

V. Phone/Fax

Practice location:
  • Phone: 310-484-3967
  • Fax:
Mailing address:
  • Phone: 310-484-3967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number177047
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: