Provider Demographics
NPI:1215695549
Name:POWELL, STEPHANIE JO (RN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JO
Last Name:POWELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 DEVONSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:PRUDENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48651-9653
Mailing Address - Country:US
Mailing Address - Phone:989-573-2607
Mailing Address - Fax:
Practice Address - Street 1:1199 HARRIS AVE
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-9681
Practice Address - Country:US
Practice Address - Phone:989-362-8636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704242734163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse