Provider Demographics
NPI:1467052415
Name:POWELL, LISSIE LEE
Entity Type:Individual
Prefix:MRS
First Name:LISSIE
Middle Name:LEE
Last Name:POWELL
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 1:851 GLENSDEL DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-8835
Mailing Address - Country:US
Mailing Address - Phone:937-268-7205
Mailing Address - Fax:
Practice Address - Street 1:851 GLENSDEL DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-8835
Practice Address - Country:US
Practice Address - Phone:937-268-7205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider