Provider Demographics
NPI:1568511707
Name:POWELL, MARCELLE S (CRNA)
Entity Type:Individual
Prefix:
First Name:MARCELLE
Middle Name:S
Last Name:POWELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8027
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-8027
Mailing Address - Country:US
Mailing Address - Phone:903-526-1068
Mailing Address - Fax:903-593-4290
Practice Address - Street 1:35 MILES ST
Practice Address - Street 2:
Practice Address - City:DAMARISCOTTA
Practice Address - State:ME
Practice Address - Zip Code:04543-4047
Practice Address - Country:US
Practice Address - Phone:903-360-5104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERNA203001207L00000X
TX517142367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86321UOtherBLUE CROSS OF TX
TX8G4354Medicare ID - Type UnspecifiedTX PART B MEDICARE