Provider Demographics
NPI:1144582040
Name:A R MIZELL LLC
Entity Type:Organization
Organization Name:A R MIZELL LLC
Other - Org Name:SOUTHERN FAMILY URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:MIZELL
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:251-510-8175
Mailing Address - Street 1:PO BOX 787
Mailing Address - Street 2:
Mailing Address - City:GRAND BAY
Mailing Address - State:AL
Mailing Address - Zip Code:36541-0787
Mailing Address - Country:US
Mailing Address - Phone:228-896-7108
Mailing Address - Fax:228-896-7174
Practice Address - Street 1:1212 E PASS RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3403
Practice Address - Country:US
Practice Address - Phone:228-896-7108
Practice Address - Fax:228-896-7174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-15
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS255642Medicare PIN