Provider Demographics
NPI:1972668754
Name:MONTICELLO POWELL, MARY ELIZABETH (APRN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELIZABETH
Last Name:MONTICELLO POWELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:410 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4203
Mailing Address - Country:US
Mailing Address - Phone:863-419-2188
Mailing Address - Fax:863-419-2540
Practice Address - Street 1:410 S 11TH ST
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4203
Practice Address - Country:US
Practice Address - Phone:863-419-2188
Practice Address - Fax:863-419-2540
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5976363L00000X
FLARNP2085022363L00000X
FLAPRN2085022363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner