Provider Demographics
NPI:1760400246
Name:POWELL, DEANNA LYNN (MD)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:LYNN
Last Name:POWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501E STONER AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4243
Mailing Address - Country:US
Mailing Address - Phone:318-990-4790
Mailing Address - Fax:318-429-5748
Practice Address - Street 1:501E STONER AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4243
Practice Address - Country:US
Practice Address - Phone:318-990-4790
Practice Address - Fax:318-429-5748
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022340207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1684848Medicaid
LAG34644Medicare UPIN
LA5Y012F600Medicare ID - Type Unspecified