Provider Demographics
NPI:1821542127
Name:POWELL, JUSTINE (CNM)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:435-716-1920
Mailing Address - Fax:
Practice Address - Street 1:1400 N 500 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2455
Practice Address - Country:US
Practice Address - Phone:435-716-1920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-04
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife