Provider Demographics
NPI:1447609516
Name:MIZENER, SAMUEL ANDREW (MED, LAT, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ANDREW
Last Name:MIZENER
Suffix:
Gender:M
Credentials:MED, LAT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 AVALON PARK BLVD S
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-7764
Mailing Address - Country:US
Mailing Address - Phone:724-831-8521
Mailing Address - Fax:
Practice Address - Street 1:1001 AVALON PARK BLVD S
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-7764
Practice Address - Country:US
Practice Address - Phone:724-831-8521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL22352255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer