Provider Demographics
NPI:1063633758
Name:POWELL, VINCENT LAMARR JR (FNP)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:LAMARR
Last Name:POWELL
Suffix:JR
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:VINCENT
Other - Middle Name:LAMARR
Other - Last Name:POWELL
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 210
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:CA
Mailing Address - Zip Code:95366-0210
Mailing Address - Country:US
Mailing Address - Phone:209-599-4211
Mailing Address - Fax:209-599-4341
Practice Address - Street 1:2275 F ST STE 1&2
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:CA
Practice Address - Zip Code:95334-1778
Practice Address - Country:US
Practice Address - Phone:209-394-8854
Practice Address - Fax:209-394-8895
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN281973163WM0705X
CA95003522363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95003492OtherFNP