=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255706446
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEGAN E MIZELL FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2015
-----------------------------------------------------
Last Update Date | 01/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 391 S 1ST ST
-----------------------------------------------------
City | JESUP
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31545-1132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-427-8433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2730 US HIGHWAY 441 N
-----------------------------------------------------
City | PEARSON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31642-4839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-422-4839
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | RN211371
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------