Provider Demographics
NPI:1902958663
Name:POWELL, MARY ELIZABETH (ARNP/CNM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:POWELL
Suffix:
Gender:F
Credentials:ARNP/CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2675 N DECATUR RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6131
Mailing Address - Country:US
Mailing Address - Phone:404-294-0472
Mailing Address - Fax:404-294-1558
Practice Address - Street 1:2675 N DECATUR RD
Practice Address - Street 2:SUITE 300
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6131
Practice Address - Country:US
Practice Address - Phone:404-294-0472
Practice Address - Fax:404-294-1558
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2015-04-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FL9301508367A00000X, 363L00000X
GARN068688367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001821300Medicaid