Provider Demographics
NPI:1902151970
Name:MIZELLE, ELIZABETH LEE (DO)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:LEE
Last Name:MIZELLE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:ELIZABETH
Other - Middle Name:T
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 602195
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2195
Mailing Address - Country:US
Mailing Address - Phone:919-350-0351
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:400 US 70 HIGHWAY E
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-4049
Practice Address - Country:US
Practice Address - Phone:919-235-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ0098207Q00000X
NC2015-00659207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1902151970Medicaid