Provider Demographics
NPI:1558147405
Name:MIZENKO, MADISON TAYLOR (APRN, AGNP-C)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:TAYLOR
Last Name:MIZENKO
Suffix:
Gender:F
Credentials:APRN, AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 SAYBROOK RD
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:CT
Mailing Address - Zip Code:06426-1401
Mailing Address - Country:US
Mailing Address - Phone:860-767-9998
Mailing Address - Fax:
Practice Address - Street 1:20 SAYBROOK RD
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426-1401
Practice Address - Country:US
Practice Address - Phone:860-767-9998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTAG09230034363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health