Provider Demographics
NPI:1639532559
Name:POWELL, REBECCA (APRN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 FOUNTAIN DRIVE
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-3684
Mailing Address - Country:US
Mailing Address - Phone:501-328-0055
Mailing Address - Fax:501-328-2194
Practice Address - Street 1:3010 FOUNTAIN DRIVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-3684
Practice Address - Country:US
Practice Address - Phone:501-328-0055
Practice Address - Fax:501-328-2194
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA003855363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR213832758Medicaid