Provider Demographics
NPI:1457892648
Name:MIZELL, LAURA (NP-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MIZELL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4581 FM 3081 RD
Mailing Address - Street 2:
Mailing Address - City:WILLIS
Mailing Address - State:TX
Mailing Address - Zip Code:77378-2403
Mailing Address - Country:US
Mailing Address - Phone:936-203-7787
Mailing Address - Fax:
Practice Address - Street 1:21300 EVA ST STE 100
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77356-1899
Practice Address - Country:US
Practice Address - Phone:936-597-8585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP131358364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health