Provider Demographics
NPI: | 1629122817 |
---|---|
Name: | POWERS, LAURIE ANN (PA-C) |
Entity Type: | Individual |
Prefix: | MRS |
First Name: | LAURIE |
Middle Name: | ANN |
Last Name: | POWERS |
Suffix: | |
Gender: | F |
Credentials: | PA-C |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 109 S CHURCHILL DR |
Mailing Address - Street 2: | |
Mailing Address - City: | FAYETTEVILLE |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 28303-5023 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 910-322-1630 |
Mailing Address - Fax: | 910-212-6548 |
Practice Address - Street 1: | 2529 RAEFORD RD |
Practice Address - Street 2: | |
Practice Address - City: | FAYETTEVILLE |
Practice Address - State: | NC |
Practice Address - Zip Code: | 28305-5098 |
Practice Address - Country: | US |
Practice Address - Phone: | 910-212-6548 |
Practice Address - Fax: | 910-460-3967 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-01-23 |
Last Update Date: | 2023-01-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | 101381 | 101YM0800X, 363AM0700X, 363A00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |