Provider Demographics
NPI:1659566347
Name:MIZELL, LORIE ANN (PTA)
Entity Type:Individual
Prefix:MS
First Name:LORIE
Middle Name:ANN
Last Name:MIZELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6391 LAKE CHARLENE LN
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32506-8603
Mailing Address - Country:US
Mailing Address - Phone:850-426-2999
Mailing Address - Fax:
Practice Address - Street 1:6391 LAKE CHARLENE LN
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32506-8603
Practice Address - Country:US
Practice Address - Phone:850-426-2999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 20314225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant