Provider Demographics
NPI:1962837013
Name:POWELL, MACKIDA (LPN)
Entity Type:Individual
Prefix:
First Name:MACKIDA
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 S JONES BLVD
Mailing Address - Street 2:APT. #1131
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-3335
Mailing Address - Country:US
Mailing Address - Phone:702-292-7330
Mailing Address - Fax:
Practice Address - Street 1:4400 S JONES BLVD
Practice Address - Street 2:APT #1131
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-3335
Practice Address - Country:US
Practice Address - Phone:702-292-7330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLPN11149103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst