Provider Demographics
NPI:1316450661
Name:MIZELLE, LISA PAIGE (CRNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:PAIGE
Last Name:MIZELLE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2604 HIGHWAY 31 S STE 100
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35603-1506
Mailing Address - Country:US
Mailing Address - Phone:256-445-3100
Mailing Address - Fax:256-445-3104
Practice Address - Street 1:2604 HIGHWAY 31 S
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35603-1506
Practice Address - Country:US
Practice Address - Phone:256-445-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-073714363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily