Provider Demographics
NPI:1154104115
Name:MIESSE, MAKENZA LOUISE
Entity type:Individual
Prefix:
First Name:MAKENZA
Middle Name:LOUISE
Last Name:MIESSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9927 MARYSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:OSTRANDER
Mailing Address - State:OH
Mailing Address - Zip Code:43061
Mailing Address - Country:US
Mailing Address - Phone:740-602-7296
Mailing Address - Fax:
Practice Address - Street 1:9927 MARYSVILLE RD
Practice Address - Street 2:
Practice Address - City:OSTRANDER
Practice Address - State:OH
Practice Address - Zip Code:43061
Practice Address - Country:US
Practice Address - Phone:740-602-7296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker