Provider Demographics
NPI:1568832236
Name:MAZZELLA, ELIZABETH JEAN (AGNP)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:JEAN
Last Name:MAZZELLA
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 N SUMMITVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-9102
Mailing Address - Country:US
Mailing Address - Phone:989-858-0938
Mailing Address - Fax:
Practice Address - Street 1:5059 OLD 27 S
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-9590
Practice Address - Country:US
Practice Address - Phone:989-705-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704244043363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health