Healthcare Provider Details

I. General information

NPI: 1225388689
Provider Name (Legal Business Name): KRISTEN J MIZUMOTO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 01/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5930 HEISLEY RD NEIGHBORING
MENTOR OH
44060-1834
US

IV. Provider business mailing address

5930 HEISLEY RD NEIGHBORING
MENTOR OH
44060-1834
US

V. Phone/Fax

Practice location:
  • Phone: 440-639-3509
  • Fax: 440-352-2040
Mailing address:
  • Phone: 440-639-3509
  • Fax: 440-352-2040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCOA13309
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: