Provider Demographics
NPI:1295123842
Name:POWTAKIEN, VIVIAN (ARNP)
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:POWTAKIEN
Suffix:
Gender:
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 N STATE HIGHWAY 121
Mailing Address - Street 2:
Mailing Address - City:BONHAM
Mailing Address - State:TX
Mailing Address - Zip Code:75418-2346
Mailing Address - Country:US
Mailing Address - Phone:430-703-1550
Mailing Address - Fax:430-703-1558
Practice Address - Street 1:2140 N STATE HIGHWAY 121
Practice Address - Street 2:
Practice Address - City:BONHAM
Practice Address - State:TX
Practice Address - Zip Code:75418-2346
Practice Address - Country:US
Practice Address - Phone:430-703-1550
Practice Address - Fax:430-703-1558
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-06
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP141251363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner