Healthcare Provider Details

I. General information

NPI: 1700509049
Provider Name (Legal Business Name): SYDNEY WADE MIZELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2022
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 WASHINGTON ST
FRANKLINTON LA
70438-6900
US

IV. Provider business mailing address

821 TAMPA ST
BOGALUSA LA
70427-2943
US

V. Phone/Fax

Practice location:
  • Phone: 985-839-5450
  • Fax:
Mailing address:
  • Phone: 985-750-9975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPST.024521
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: