Provider Demographics
NPI:1639449903
Name:SHIVELY MIZES, CAROL S (MT-BC, NMT FELLOW)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:S
Last Name:SHIVELY MIZES
Suffix:
Gender:F
Credentials:MT-BC, NMT FELLOW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14924 ROYAL RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:NORTH ROYALTON
Mailing Address - State:OH
Mailing Address - Zip Code:44133-4864
Mailing Address - Country:US
Mailing Address - Phone:440-749-1864
Mailing Address - Fax:
Practice Address - Street 1:14924 ROYAL RIDGE LN
Practice Address - Street 2:
Practice Address - City:NORTH ROYALTON
Practice Address - State:OH
Practice Address - Zip Code:44133-4864
Practice Address - Country:US
Practice Address - Phone:440-749-1864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH07300172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker