Healthcare Provider Details

I. General information

NPI: 1871034082
Provider Name (Legal Business Name): JUSTIN ROBERT POWELL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 US HIGHWAY 431
BOAZ AL
35957-5908
US

IV. Provider business mailing address

800 EAST CARPENTER STREET
SPRINGFIELD IL
62702
US

V. Phone/Fax

Practice location:
  • Phone: 256-593-8310
  • Fax: 256-840-3647
Mailing address:
  • Phone: 217-544-6464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209016109
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: