Provider Demographics
NPI:1942835434
Name:POWERS, KEVIN C (RN)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
Last Name:POWERS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 S 350 E # 32-1
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-3344
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:ROUTE 264 MP 388
Practice Address - Street 2:
Practice Address - City:POLACCA
Practice Address - State:AZ
Practice Address - Zip Code:86042
Practice Address - Country:US
Practice Address - Phone:928-737-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9008535-3102163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ020529Medicaid