Provider Demographics
NPI:1629595533
Name:POWELL, MICHON LYNETTE (MS, CNS, LDN)
Entity Type:Individual
Prefix:
First Name:MICHON
Middle Name:LYNETTE
Last Name:POWELL
Suffix:
Gender:F
Credentials:MS, CNS, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9603 GREYFIELD CT
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-3180
Mailing Address - Country:US
Mailing Address - Phone:301-466-6493
Mailing Address - Fax:
Practice Address - Street 1:9135 PISCATAWAY RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-2549
Practice Address - Country:US
Practice Address - Phone:240-348-7860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX3766133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty