Provider Demographics
NPI:1023336583
Name:POWELL, KIMBERLY LOUISE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LOUISE
Last Name:POWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:LOUISE
Other - Last Name:HEBELER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1382 BISHOP RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1146
Mailing Address - Country:US
Mailing Address - Phone:508-922-8064
Mailing Address - Fax:
Practice Address - Street 1:6071 W OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2624
Practice Address - Country:US
Practice Address - Phone:313-966-6870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-08
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005713363A00000X
OH50.003040363A00000X
NJ25MP00236100363A00000X
CT004207363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical