Provider Demographics
NPI:1851408025
Name:POWELL, MARIROSE (FNP)
Entity Type:Individual
Prefix:
First Name:MARIROSE
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARIROSE
Other - Middle Name:
Other - Last Name:GREGSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1156 NORTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-0443
Mailing Address - Country:US
Mailing Address - Phone:209-423-4074
Mailing Address - Fax:
Practice Address - Street 1:1805 N CALIFORNIA ST STE 406
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-6033
Practice Address - Country:US
Practice Address - Phone:209-227-7806
Practice Address - Fax:209-851-3853
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANPF13060363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily