Provider Demographics
NPI:1083180814
Name:POWELL, COURTNEY JENNINGS (PA-C)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:JENNINGS
Last Name:POWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:LOUISE
Other - Last Name:JENNINGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:45 WRENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27527-3384
Mailing Address - Country:US
Mailing Address - Phone:919-801-6918
Mailing Address - Fax:
Practice Address - Street 1:236 BUTTERNUT LN
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-5857
Practice Address - Country:US
Practice Address - Phone:919-359-1011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-19
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08514363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant