Provider Demographics
NPI:1255615712
Name:POWNALL, MICHELLE (APRN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:POWNALL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-345-7579
Mailing Address - Fax:
Practice Address - Street 1:930 S HARBOR CITY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1901
Practice Address - Country:US
Practice Address - Phone:321-345-7579
Practice Address - Fax:833-944-2173
Is Sole Proprietor?:No
Enumeration Date:2011-10-03
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN3168612363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLO3902OtherMEDICARE HF
FLY09HXOtherFLORIDA BLUE
FLP01165560OtherRR MEDICARE GROUP DT5990
FL9592477OtherAETNA
FLFS034WOtherMEDICARE