Provider Demographics
NPI:1194038786
Name:POWELL, STANLEY WAYNE JR (MS OTR/L)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:WAYNE
Last Name:POWELL
Suffix:JR
Gender:M
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 HILLS CT
Mailing Address - Street 2:
Mailing Address - City:ARKADELPHIA
Mailing Address - State:AR
Mailing Address - Zip Code:71923-5451
Mailing Address - Country:US
Mailing Address - Phone:479-651-8289
Mailing Address - Fax:
Practice Address - Street 1:13073 SE 26TH ST APT D101
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-4262
Practice Address - Country:US
Practice Address - Phone:479-651-8289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-23
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR2311172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker