Provider Demographics
NPI:1962779744
Name:POWELL, LYDELL (CSFA)
Entity type:Individual
Prefix:
First Name:LYDELL
Middle Name:
Last Name:POWELL
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1897 HOLLYHOCK CIR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-4701
Mailing Address - Country:US
Mailing Address - Phone:505-360-7709
Mailing Address - Fax:
Practice Address - Street 1:1897 HOLLYHOCK CIR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-4701
Practice Address - Country:US
Practice Address - Phone:505-360-7709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-22
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant