Healthcare Provider Details

I. General information

NPI: 1902151970
Provider Name (Legal Business Name): ELIZABETH LEE MIZELLE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELIZABETH T LEE D.O.

II. Dates (important events)

Enumeration Date: 07/17/2012
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 US 70 HIGHWAY E
GARNER NC
27529-4049
US

IV. Provider business mailing address

PO BOX 602195
CHARLOTTE NC
28260-2195
US

V. Phone/Fax

Practice location:
  • Phone: 919-235-6400
  • Fax:
Mailing address:
  • Phone: 919-350-0351
  • Fax: 919-350-7687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberQ0098
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2015-00659
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: