Provider Demographics
NPI:1740264779
Name:POWELL, MARY V (RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:V
Last Name:POWELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 W HUNTINGTON DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-3495
Mailing Address - Country:US
Mailing Address - Phone:626-353-8531
Mailing Address - Fax:
Practice Address - Street 1:289 W HUNTINGTON DR STE 205
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-3492
Practice Address - Country:US
Practice Address - Phone:626-353-8531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA542206163WA2000X, 163WP2201X, 163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ479594Medicaid
AZ430079592OtherRAILROAD MEDICARE
AZZ73101Medicare PIN
AZ430079592OtherRAILROAD MEDICARE