Provider Demographics
NPI:1538164447
Name:POWELL-ALLEN, BRENDA (CWNP)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:POWELL-ALLEN
Suffix:
Gender:F
Credentials:CWNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 393
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-0393
Mailing Address - Country:US
Mailing Address - Phone:309-833-2868
Mailing Address - Fax:309-836-3779
Practice Address - Street 1:505 E GRANT ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3352
Practice Address - Country:US
Practice Address - Phone:309-833-5959
Practice Address - Fax:309-833-4969
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health