Provider Demographics
NPI:1558837393
Name:POWELL, MARY ROSE
Entity Type:Individual
Prefix:
First Name:MARY ROSE
Middle Name:
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 1:130 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:TUNKHANNOCK
Mailing Address - State:PA
Mailing Address - Zip Code:18657-1354
Mailing Address - Country:US
Mailing Address - Phone:570-836-7771
Mailing Address - Fax:570-836-1890
Practice Address - Street 1:130 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:TUNKHANNOCK
Practice Address - State:PA
Practice Address - Zip Code:18657-1354
Practice Address - Country:US
Practice Address - Phone:570-836-7771
Practice Address - Fax:570-836-1890
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-19
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA3359237600000X, 237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter