Provider Demographics
NPI:1164031043
Name:POWELL, MORANDA MONE'T (RN)
Entity type:Individual
Prefix:
First Name:MORANDA
Middle Name:MONE'T
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 1:3208 HATCHER RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71119-5334
Mailing Address - Country:US
Mailing Address - Phone:318-799-4927
Mailing Address - Fax:
Practice Address - Street 1:3208 HATCHER RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71119-5334
Practice Address - Country:US
Practice Address - Phone:318-799-4927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN147886163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherN/A