Provider Demographics
NPI:1700854189
Name:POWELL, SALLY MITCHELL (NP)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:MITCHELL
Last Name:POWELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:803 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30642-1211
Mailing Address - Country:US
Mailing Address - Phone:706-453-1201
Mailing Address - Fax:706-453-2954
Practice Address - Street 1:1041 PARK DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-3465
Practice Address - Country:US
Practice Address - Phone:706-453-4945
Practice Address - Fax:706-453-2954
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN089650363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ24195Medicare UPIN