Healthcare Provider Details

I. General information

NPI: 1659213544
Provider Name (Legal Business Name): MIELLIE BAZZANO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIELLIE BAZZANO-COOK

II. Dates (important events)

Enumeration Date: 04/08/2026
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 CLOVER VALLEY RD
UPPER LAKE CA
95485-9220
US

IV. Provider business mailing address

18262 N SHORE DR
HIDDEN VALLEY LAKE CA
95467-8624
US

V. Phone/Fax

Practice location:
  • Phone: 707-900-8994
  • Fax:
Mailing address:
  • Phone: 707-900-8994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number20733
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: