Provider Demographics
NPI:1295043602
Name:MIZELLE, SUSAN (PA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MIZELLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:SALYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1185 W MOUNTAIN VIEW RD
Mailing Address - Street 2:APARTMENT 1301
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2523
Mailing Address - Country:US
Mailing Address - Phone:423-276-4033
Mailing Address - Fax:
Practice Address - Street 1:400 N STATE OF FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6035
Practice Address - Country:US
Practice Address - Phone:423-431-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-20
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA1883363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical