Provider Demographics
NPI:1881178036
Name:MIZERA-LIESKE, KIMBERLYN (ND)
Entity type:Individual
Prefix:
First Name:KIMBERLYN
Middle Name:
Last Name:MIZERA-LIESKE
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8175 E EVANS RD UNIT 15101
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85267-5080
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9700 N 91ST ST STE A115
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-5036
Practice Address - Country:US
Practice Address - Phone:480-616-2549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-23
Last Update Date:2018-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18-1734175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath