Provider Demographics
NPI:1356753461
Name:POWELL, KAITLYN (MD)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 CHAFEE AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-5810
Mailing Address - Country:US
Mailing Address - Phone:706-721-6231
Mailing Address - Fax:706-721-6220
Practice Address - Street 1:1706 SAINT JULIAN PL
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2410
Practice Address - Country:US
Practice Address - Phone:803-771-7506
Practice Address - Fax:803-771-9455
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-22
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD51986207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology