Provider Demographics
NPI:1770214264
Name:POWELL, TISHA (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:TISHA
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:871 WINDING WOOD DR
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36093-1685
Mailing Address - Country:US
Mailing Address - Phone:334-328-5138
Mailing Address - Fax:
Practice Address - Street 1:871 WINDING WOOD DR
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36093-1685
Practice Address - Country:US
Practice Address - Phone:334-328-5138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1097398163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant