Basic Information
| Provider Information | |||||||||
| NPI: | 1366753428 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POWERS | ||||||||
| FirstName: | MICAHLYN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5580 NORDIC WAY | ||||||||
| Address2: | |||||||||
| City: | FERNDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603841511 | ||||||||
| FaxNumber: | 3603845758 | ||||||||
| Practice Location | |||||||||
| Address1: | 5580 NORDIC WAY | ||||||||
| Address2: | |||||||||
| City: | FERNDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603841511 | ||||||||
| FaxNumber: | 3603845758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2010 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD60335430 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2029380 | 05 | WA | MEDICAID | 0322502 | 01 | WA | LABOR AND INDUSTRIES | OTHER |