Healthcare Provider Details

I. General information

NPI: 1790453942
Provider Name (Legal Business Name): SHANIQUA POWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2021
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

547 E LEE ST
DAWSON GA
39842-1555
US

IV. Provider business mailing address

547 E LEE ST
DAWSON GA
39842-1555
US

V. Phone/Fax

Practice location:
  • Phone: 229-338-0602
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: