Healthcare Provider Details

I. General information

NPI: 1720912165
Provider Name (Legal Business Name): LAWANDA MIZZELLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 N SMITHFIELD RD
KNIGHTDALE NC
27545-7726
US

IV. Provider business mailing address

2901 FLINTRIDGE DR
GREENVILLE NC
27834-4963
US

V. Phone/Fax

Practice location:
  • Phone: 858-465-2148
  • Fax:
Mailing address:
  • Phone: 858-465-2148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: