Healthcare Provider Details

I. General information

NPI: 1316178486
Provider Name (Legal Business Name): LAKEILA TACHELLE POWELL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2009
Last Update Date: 08/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9159 FRANKTOWN ROAD
FRANKTOWN VA
23354-0009
US

IV. Provider business mailing address

PO BOX 9
FRANKTOWN VA
23354-0009
US

V. Phone/Fax

Practice location:
  • Phone: 757-442-4819
  • Fax: 757-442-9505
Mailing address:
  • Phone: 757-442-4819
  • Fax: 757-442-9505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110003080
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: