Individual
MRS. VANESSA KELLY MIZAK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FNP-C, AGCNS-BC
Contact information
Practice address
3600 NW SAMARITAN DR STE 227, CORVALLIS, OR 97330-3737
(541) 768-1261
Mailing address
PO BOX 1189, CORVALLIS, OR 97339-1189
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
201804760NP-PP
OR
363LF0000X
Family Nurse Practitioner
0993810
CO
364S00000X
Clinical Nurse Specialist
201804762CNS
OR
364S00000X
Clinical Nurse Specialist
APN.0991563-CNS
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
85780073
—
CO
01
—
P01618686
MCR RAILROAD
CO
Enumeration date
01/08/2015
Last updated
09/13/2021
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