Healthcare Provider Details

I. General information

NPI: 1114438199
Provider Name (Legal Business Name): TABATHA KRISTI MIZE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2017
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17400 ST LUKES WAY
THE WOODLANDS TX
77384-8036
US

IV. Provider business mailing address

154 HARLEY DR
MONTGOMERY TX
77356-8812
US

V. Phone/Fax

Practice location:
  • Phone: 936-266-9000
  • Fax:
Mailing address:
  • Phone: 936-672-2961
  • Fax: 936-672-2961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP135492
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: