Healthcare Provider Details

I. General information

NPI: 1659566347
Provider Name (Legal Business Name): LORIE ANN MIZELL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 09/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6391 LAKE CHARLENE LN
PENSACOLA FL
32506-8603
US

IV. Provider business mailing address

6391 LAKE CHARLENE LN
PENSACOLA FL
32506-8603
US

V. Phone/Fax

Practice location:
  • Phone: 850-426-2999
  • Fax:
Mailing address:
  • Phone: 850-426-2999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 20314
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: