Healthcare Provider Details

I. General information

NPI: 1255615712
Provider Name (Legal Business Name): MICHELLE POWNALL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2011
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 S HARBOR CITY BLVD STE 100
MELBOURNE FL
32901-1901
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-345-7579
  • Fax: 833-944-2173
Mailing address:
  • Phone: 321-345-7579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN3168612
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: