Basic Information
| Provider Information | |||||||||
| NPI: | 1225388689 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIZUMOTO | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5930 HEISLEY RD | ||||||||
| Address2: | NEIGHBORING | ||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440601834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406393509 | ||||||||
| FaxNumber: | 4403522040 | ||||||||
| Practice Location | |||||||||
| Address1: | 5930 HEISLEY RD | ||||||||
| Address2: | NEIGHBORING | ||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440601834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406393509 | ||||||||
| FaxNumber: | 4403522040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2012 | ||||||||
| LastUpdateDate: | 01/31/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | COA13309 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 2362429 | 05 | OH | MEDICAID |