MEDICARE: MS. LORIE ANN MIZELL PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	PTA 20314	FL

General Provider Information

NPI Number	:	1659566347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LORIE ANN MIZELL PTA

Provider Business Mailing Address
First Line	:	6391 LAKE CHARLENE LN
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32506-8603
Country	:	US
Telephone Number	:	850-426-2999
Fax Number	:

Provider Business Practice Location Address
First Line	:	6391 LAKE CHARLENE LN
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32506-8603
Country	:	US
Telephone Number	:	850-426-2999
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2007
Last Update Date	:	09/06/2007

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