Provider Demographics
NPI:1073053260
Name:POWELL, GINA C (RN)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:C
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 1:1416 E MATTHEWS AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4362
Mailing Address - Country:US
Mailing Address - Phone:870-207-7825
Mailing Address - Fax:
Practice Address - Street 1:1416 E MATTHEWS AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4362
Practice Address - Country:US
Practice Address - Phone:870-207-7825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR051390163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)