Provider Demographics
NPI:1417040403
Name:POWELL, STEPHANIE PEARLETTE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:PEARLETTE
Last Name:POWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:500 E 51ST ST
Mailing Address - Street 2:ROOM 7021E
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-2400
Mailing Address - Country:US
Mailing Address - Phone:773-572-2743
Mailing Address - Fax:773-572-2799
Practice Address - Street 1:500 E 51ST ST
Practice Address - Street 2:ROOM 7021E
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-2400
Practice Address - Country:US
Practice Address - Phone:312-572-2743
Practice Address - Fax:312-572-2799
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085-001414363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085001414OtherPA LICENSE NUMBER