Healthcare Provider Details

I. General information

NPI: 1538810148
Provider Name (Legal Business Name): BRANDY LARA MIZER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2022
Last Update Date: 01/14/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 CHESTNUT ST
COSHOCTON OH
43812-1131
US

IV. Provider business mailing address

26180 STATE ROUTE 83
COSHOCTON OH
43812-9626
US

V. Phone/Fax

Practice location:
  • Phone: 740-622-7284
  • Fax:
Mailing address:
  • Phone: 740-502-8033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.451601
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: