Healthcare Provider Details

I. General information

NPI: 1134222169
Provider Name (Legal Business Name): SHIRLEY LUCILLE POWELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHIRLEY KIGHTLINGER POWELL PA-C

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 03/07/2023
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 AIRPARK DR STE 104
REDDING CA
96001-2461
US

IV. Provider business mailing address

3400 DATA DR ATTN: CREDENTIALING/PAYER ENROLLMENT
RANCHO CORDOVA CA
95670-7956
US

V. Phone/Fax

Practice location:
  • Phone: 530-242-3570
  • Fax: 530-242-3572
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number672043
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number16701
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: