Provider Demographics
NPI:1356081277
Name:POVEROMO, EMMA LOUISE
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:LOUISE
Last Name:POVEROMO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 76 BOX 3385
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96319-0034
Mailing Address - Country:US
Mailing Address - Phone:315-226-6647
Mailing Address - Fax:
Practice Address - Street 1:BUILDING 99 MISAWA AB
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96319
Practice Address - Country:US
Practice Address - Phone:315-226-6647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians