Provider Demographics
NPI:1356744049
Name:POWELL, WILLIE (MPA)
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5220 4TH AVE
Mailing Address - Street 2:BROOKLYN
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-1812
Mailing Address - Country:US
Mailing Address - Phone:718-360-8169
Mailing Address - Fax:
Practice Address - Street 1:5220 4TH AVE
Practice Address - Street 2:BROOKLYN
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-1812
Practice Address - Country:US
Practice Address - Phone:718-360-8169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker