Provider Demographics
NPI:1174950562
Name:POWELL, KRISTA JANE (LPN)
Entity type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:JANE
Last Name:POWELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 EASTERN ST
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-5381
Mailing Address - Country:US
Mailing Address - Phone:928-753-1919
Mailing Address - Fax:928-753-1418
Practice Address - Street 1:350 EASTERN ST
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-5381
Practice Address - Country:US
Practice Address - Phone:928-753-1919
Practice Address - Fax:928-753-1418
Is Sole Proprietor?:No
Enumeration Date:2013-10-01
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP048050164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse