Provider Demographics
NPI:1023133444
Name:MIZIK, CAROL P
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:P
Last Name:MIZIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 106
Mailing Address - Street 2:
Mailing Address - City:BELLE VALLEY
Mailing Address - State:OH
Mailing Address - Zip Code:43717-0106
Mailing Address - Country:US
Mailing Address - Phone:740-732-1347
Mailing Address - Fax:
Practice Address - Street 1:230 BROWN STREET
Practice Address - Street 2:
Practice Address - City:BELLE VALLEY
Practice Address - State:OH
Practice Address - Zip Code:43717-0106
Practice Address - Country:US
Practice Address - Phone:740-732-1347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH076665164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2399462Medicaid