Basic Information
| Provider Information | |||||||||
| NPI: | 1225129190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POWELL | ||||||||
| FirstName: | FRED | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | R.N., BSN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6128 E 38TH ST | ||||||||
| Address2: | SUITE# 305 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741355832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185997404 | ||||||||
| FaxNumber: | 9185842530 | ||||||||
| Practice Location | |||||||||
| Address1: | 6128 E 38TH ST | ||||||||
| Address2: | SUITE# 305 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741355832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185997404 | ||||||||
| FaxNumber: | 9185842530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0809X | R0058270 | OK | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult |
No ID Information.