Healthcare Provider Details

I. General information

NPI: 1265033799
Provider Name (Legal Business Name): BRIANNA POWELL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2020
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 JAMES SIMPSON JR WAY
COVINGTON KY
41011-0801
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-655-8910
  • Fax: 859-655-8911
Mailing address:
  • Phone: 859-344-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number172126
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: