Provider Demographics
NPI:1194725432
Name:POWELL, JOHN H (NP)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:H
Last Name:POWELL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:80 HUMPHREYS CENTER DR STE 330
Practice Address - Street 2:STE 300
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2363
Practice Address - Country:US
Practice Address - Phone:901-752-6131
Practice Address - Fax:901-752-6167
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA001321363LF0000X
MS810081363LF0000X
TN7041363LF0000X
TNAPN-7041363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04620218Medicaid
AR180172758Medicaid
TNQ010344Medicaid
TN103I501049Medicare PIN
MS302I501075Medicare PIN