Provider Demographics
NPI:1356096382
Name:POWELL, DERWIN (RN)
Entity Type:Individual
Prefix:
First Name:DERWIN
Middle Name:
Last Name:POWELL
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 SHILOH VALLEY DR NW APT 1323
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-3179
Mailing Address - Country:US
Mailing Address - Phone:931-216-8092
Mailing Address - Fax:
Practice Address - Street 1:2100 SHILOH VALLEY DR NW APT 1323
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-3179
Practice Address - Country:US
Practice Address - Phone:931-216-8092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA203006163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse