Provider Demographics
NPI:1194523001
Name:POWELL-BLACKWELL, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:POWELL-BLACKWELL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 LAMON ST STE 124
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-4917
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 LAMON ST STE 124
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-4917
Practice Address - Country:US
Practice Address - Phone:910-286-5912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-05
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC7793332U00000X, 343900000X, 372600000X, 374U00000X, 385H00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No332U00000XSuppliersHome Delivered Meals
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No372600000XNursing Service Related ProvidersAdult Companion
No374U00000XNursing Service Related ProvidersHome Health Aide
No385H00000XRespite Care FacilityRespite Care