Provider Demographics
NPI:1407112139
Name:POWELL-WILSON, LENEE (RN)
Entity Type:Individual
Prefix:
First Name:LENEE
Middle Name:
Last Name:POWELL-WILSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4619 FOX VALLEY DR APT 2A
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-8197
Mailing Address - Country:US
Mailing Address - Phone:630-205-6137
Mailing Address - Fax:
Practice Address - Street 1:4619 FOX VALLEY DR APT 2A
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-8197
Practice Address - Country:US
Practice Address - Phone:630-205-6137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-06
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704283731163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse