Healthcare Provider Details

I. General information

NPI: 1194038786
Provider Name (Legal Business Name): STANLEY WAYNE POWELL JR. MS OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2010
Last Update Date: 07/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13073 SE 26TH ST APT D101
BELLEVUE WA
98005-4262
US

IV. Provider business mailing address

4 HILLS CT
ARKADELPHIA AR
71923-5451
US

V. Phone/Fax

Practice location:
  • Phone: 479-651-8289
  • Fax:
Mailing address:
  • Phone: 479-651-8289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberOTR2311
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: