Provider Demographics
NPI:1285207159
Name:POWELL, NICHOLAS
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:POWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 WOOSTER ST NE
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:OH
Mailing Address - Zip Code:44662-1044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 MAIN ST N
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:OH
Practice Address - Zip Code:44662-1159
Practice Address - Country:US
Practice Address - Phone:330-324-2086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities