Provider Demographics
NPI:1356763973
Name:POWELL, TAMELRA
Entity type:Individual
Prefix:
First Name:TAMELRA
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2352 RIVA RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:IL
Mailing Address - Zip Code:60538-3407
Mailing Address - Country:US
Mailing Address - Phone:630-966-2012
Mailing Address - Fax:630-966-2010
Practice Address - Street 1:2352 RIVA RIDGE RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:IL
Practice Address - Zip Code:60538-3407
Practice Address - Country:US
Practice Address - Phone:630-966-2012
Practice Address - Fax:630-966-2010
Is Sole Proprietor?:No
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL462608967172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver