Basic Information
| Provider Information | |||||||||
| NPI: | 1508472382 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOWEN | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | EILEEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12409 W PALO VERDE DR | ||||||||
| Address2: | |||||||||
| City: | LITCHFIELD PARK | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853403801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802745264 | ||||||||
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| Practice Location | |||||||||
| Address1: | 19420 N 59TH AVE STE H830 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853086980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233029020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2020 | ||||||||
| LastUpdateDate: | 09/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.