Provider Demographics
NPI:1689185225
Name:POWELL, KRISTIE DELANE (MA)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIE
Middle Name:DELANE
Last Name:POWELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5707 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-4350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6220 N NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-6257
Practice Address - Country:US
Practice Address - Phone:813-272-3766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-23
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL104100000X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health