Provider Demographics
NPI:1275086902
Name:POWELL, DIOSAN MANGUBAT (FNP)
Entity Type:Individual
Prefix:MRS
First Name:DIOSAN
Middle Name:MANGUBAT
Last Name:POWELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:DIOSAN
Other - Middle Name:MANGUBAT
Other - Last Name:AGAGDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:5248 GARNER LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-6016
Mailing Address - Country:US
Mailing Address - Phone:615-585-0469
Mailing Address - Fax:
Practice Address - Street 1:346 STATELINE RD W
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1610
Practice Address - Country:US
Practice Address - Phone:662-510-5353
Practice Address - Fax:662-510-0409
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-29
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21474363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08778361Medicaid