Provider Demographics
NPI:1083951867
Name:MIZELL, TRICIA MARIE (RT (R) (ARRT))
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:MARIE
Last Name:MIZELL
Suffix:
Gender:F
Credentials:RT (R) (ARRT)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 HARDEMAN AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-1441
Mailing Address - Country:US
Mailing Address - Phone:478-745-3135
Mailing Address - Fax:478-745-3136
Practice Address - Street 1:1504 HARDEMAN AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1441
Practice Address - Country:US
Practice Address - Phone:478-745-3135
Practice Address - Fax:478-745-3136
Is Sole Proprietor?:No
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA496508247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist