Provider Demographics
NPI:1710650007
Name:POWELL, MILLICENT ALICIA
Entity Type:Individual
Prefix:
First Name:MILLICENT
Middle Name:ALICIA
Last Name:POWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 ED GRAY DR APT 7B
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-6622
Mailing Address - Country:US
Mailing Address - Phone:662-394-1744
Mailing Address - Fax:
Practice Address - Street 1:1920 LISA DRIVE EXT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-4408
Practice Address - Country:US
Practice Address - Phone:662-335-2897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-01
Last Update Date:2021-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care