MEDICARE: CONNIE MICHELLE POWELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	1073265	TX

General Provider Information

NPI Number	:	1053051615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONNIE MICHELLE POWELL

Provider Business Mailing Address
First Line	:	14703 EAGLE VISTA DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77077-5394
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	18110 GOLDEN FALLS LN
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77379-1499
Country	:	US
Telephone Number	:	281-705-4958
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2022
Last Update Date	:	03/31/2022

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