Provider Demographics
NPI:1730340563
Name:POWELL, KAYTI A (CPNP)
Entity type:Individual
Prefix:
First Name:KAYTI
Middle Name:A
Last Name:POWELL
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1488 HWY 487 EAST
Mailing Address - Street 2:PO BOX 150
Mailing Address - City:SEBASTOPOL
Mailing Address - State:MS
Mailing Address - Zip Code:39359-0150
Mailing Address - Country:US
Mailing Address - Phone:601-625-7403
Mailing Address - Fax:601-625-7404
Practice Address - Street 1:1488 HWY 487 EAST
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:MS
Practice Address - Zip Code:39359-0150
Practice Address - Country:US
Practice Address - Phone:601-625-7403
Practice Address - Fax:601-625-7404
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-24
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR864059363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06685060Medicaid
MS512I500524Medicare PIN