1912080359 NPI number — DR. ABIGAIL DORMIRE POWERS PH.D.

Table of content: (NPI 1174713655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912080359 NPI number — DR. ABIGAIL DORMIRE POWERS PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POWERS
Provider First Name:
ABIGAIL
Provider Middle Name:
DORMIRE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912080359
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3606 NEW VISION DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46845-1706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-373-1930
Provider Business Mailing Address Fax Number:
260-373-1933

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10311 DAWSONS CREEK BLVD
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46825-1913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-490-5800
Provider Business Practice Location Address Fax Number:
260-490-8722
Provider Enumeration Date:
10/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  20040449A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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