MEDICARE: DR. DEEDDA RENAE POWELL DNP-PMHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	POWE-X2E45	NC

General Provider Information

NPI Number	:	1194443788
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEEDDA RENAE POWELL DNP-PMHNP

Provider Business Mailing Address
First Line	:	4801 E INDEPENDENCE BLVD STE 501
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28212-5494
Country	:	US
Telephone Number	:	704-890-4309
Fax Number	:

Provider Business Practice Location Address
First Line	:	4801 E INDEPENDENCE BLVD STE 501
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28212-5494
Country	:	US
Telephone Number	:	704-388-6736
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2022
Last Update Date	:	02/27/2025

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