Healthcare Provider Details

I. General information

NPI: 1043354301
Provider Name (Legal Business Name): PAMALA DAWN MIZE M.S. CCC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 VIRGINIA AVE
WYTHEVILLE VA
24382-1185
US

IV. Provider business mailing address

195 W PINE ST # 103
WYTHEVILLE VA
24382-1954
US

V. Phone/Fax

Practice location:
  • Phone: 276-620-3546
  • Fax: 276-228-3546
Mailing address:
  • Phone: 276-620-3546
  • Fax: 276-228-3546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number2201000232
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: