Healthcare Provider Details

I. General information

NPI: 1053752576
Provider Name (Legal Business Name): LISA M MAZZELLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2013
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25301 EUCLID AVE
EUCLID OH
44117-2609
US

IV. Provider business mailing address

25301 EUCLID AVE
EUCLID OH
44117-2609
US

V. Phone/Fax

Practice location:
  • Phone: 216-261-6263
  • Fax: 216-261-4964
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.334407
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number14783-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: