Provider Demographics
NPI:1194348714
Name:POWELL, CASSIDY NICOLE
Entity type:Individual
Prefix:
First Name:CASSIDY
Middle Name:NICOLE
Last Name:POWELL
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 1:2351 CEDAR HILL RD NW
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-9509
Mailing Address - Country:US
Mailing Address - Phone:937-564-8912
Mailing Address - Fax:
Practice Address - Street 1:6045 N MAIN ST APT 349
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-3194
Practice Address - Country:US
Practice Address - Phone:937-564-8912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2023-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0148623Medicaid