Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0200X | Nurse Practitioner - Pediatrics | AP091039 | ME |
NPI | 1003049768 |
---|---|
Provider Name | Ms. Nicole L. Mizner |
First Address | Portland, ME 04102-3100 |
Second Address | Portland, ME 04102-3100 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/08/2009 |
Last Update Date | 28/08/2009 |