Provider Demographics
NPI:1174806699
Name:POWELL, DEZERIE A (ARNP)
Entity type:Individual
Prefix:
First Name:DEZERIE
Middle Name:A
Last Name:POWELL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:DEZERIE
Other - Middle Name:A
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:3433 AGLER RD
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-3387
Mailing Address - Country:US
Mailing Address - Phone:614-645-5500
Mailing Address - Fax:614-458-1849
Practice Address - Street 1:3433 AGLER RD
Practice Address - Street 2:SUITE 2800
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-3387
Practice Address - Country:US
Practice Address - Phone:614-645-1600
Practice Address - Fax:614-645-1347
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP13748363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0071297Medicaid
OH20111699OtherPEDIATRIC NURSING CERTIFICATION BOARD
OHMS2736467OtherDEA
OHH377336Medicare PIN
OHH377333Medicare PIN
OHMS2736467OtherDEA
OHH377334Medicare PIN
OHH377338Medicare PIN
OHH377332Medicare PIN
OHH377337Medicare PIN
OHH377330Medicare PIN
OH0071297Medicaid