Provider Demographics
NPI:1134222169
Name:POWELL, SHIRLEY LUCILLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:LUCILLE
Last Name:POWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:SHIRLEY
Other - Middle Name:KIGHTLINGER
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:ATTN: CREDENTIALING/PAYER ENROLLMENT
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2510 AIRPARK DR STE 104
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-2461
Practice Address - Country:US
Practice Address - Phone:530-242-3570
Practice Address - Fax:530-242-3572
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
672043133V00000X
CA16701363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
09315405OtherCERTIFIED DIABETES EDUCAT
CA16701OtherPHYSICIAN ASSISTANT
672043OtherREGISTERED DIETITIAN
672043OtherREGISTERED DIETITIAN