Provider Demographics
NPI:1962398289
Name:ARDIZZONI, MIKAYLA
Entity type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:
Last Name:ARDIZZONI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 PAIGE HILL RD
Mailing Address - Street 2:
Mailing Address - City:BRIMFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01010-9779
Mailing Address - Country:US
Mailing Address - Phone:413-343-4175
Mailing Address - Fax:
Practice Address - Street 1:157 PAIGE HILL RD
Practice Address - Street 2:
Practice Address - City:BRIMFIELD
Practice Address - State:MA
Practice Address - Zip Code:01010-9779
Practice Address - Country:US
Practice Address - Phone:413-343-4175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-13
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2335581363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health