Provider Demographics
NPI:1306839857
Name:POWELL, MONICA JA (MD)
Entity Type:Individual
Prefix:DR
First Name:MONICA
Middle Name:JA
Last Name:POWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:CRAMERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28032-1401
Mailing Address - Country:US
Mailing Address - Phone:704-824-1321
Mailing Address - Fax:704-824-4816
Practice Address - Street 1:137 8TH AVE
Practice Address - Street 2:
Practice Address - City:CRAMERTON
Practice Address - State:NC
Practice Address - Zip Code:28032-1401
Practice Address - Country:US
Practice Address - Phone:704-824-1321
Practice Address - Fax:704-824-4816
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-01559208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT042620OtherCT STATE MEDICAL LICENSE
SCN01559Medicaid
NC5906890Medicaid
CT042620OtherCT STATE MEDICAL LICENSE