Healthcare Provider Details

I. General information

NPI: 1104386242
Provider Name (Legal Business Name): SARAH MIZELLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2019
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3106 W BAY TO BAY BLVD
TAMPA FL
33629-7212
US

IV. Provider business mailing address

3201 W ROGERS AVE
TAMPA FL
33611-4323
US

V. Phone/Fax

Practice location:
  • Phone: 813-692-1802
  • Fax: 833-428-4407
Mailing address:
  • Phone: 727-249-2904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9114471
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: