Provider Demographics
NPI:1700011178
Name:POWELL, KIMBERLY MICHELLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:POWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:KIMBERLY
Other - Middle Name:MICHELLE
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:2911 ROBERTS AVE
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32310-5007
Mailing Address - Country:US
Mailing Address - Phone:850-644-1543
Mailing Address - Fax:
Practice Address - Street 1:2911 ROBERTS AVE
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32310-5007
Practice Address - Country:US
Practice Address - Phone:850-644-1543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005568363AS0400X, 363A00000X
FL9117619363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA908821509AMedicaid
FL119357700Medicaid