Provider Demographics
NPI:1871034082
Name:POWELL, JUSTIN ROBERT (CRNA)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:ROBERT
Last Name:POWELL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 EAST CARPENTER STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702
Mailing Address - Country:US
Mailing Address - Phone:217-544-6464
Mailing Address - Fax:
Practice Address - Street 1:2505 US HIGHWAY 431
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957-5908
Practice Address - Country:US
Practice Address - Phone:256-593-8310
Practice Address - Fax:256-840-3647
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016109367500000X
IL041399967390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program