Provider Demographics
NPI:1225388689
Name:MIZUMOTO, KRISTEN J (NP)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:J
Last Name:MIZUMOTO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5930 HEISLEY RD
Mailing Address - Street 2:NEIGHBORING
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-1834
Mailing Address - Country:US
Mailing Address - Phone:440-639-3509
Mailing Address - Fax:440-352-2040
Practice Address - Street 1:5930 HEISLEY RD
Practice Address - Street 2:NEIGHBORING
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-1834
Practice Address - Country:US
Practice Address - Phone:440-639-3509
Practice Address - Fax:440-352-2040
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA13309363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2362429Medicaid
OH9282481Medicare UPIN