Basic Information
Provider Information | |||||||||
NPI: | 1841251600 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOWSMAN | ||||||||
FirstName: | TRACEY | ||||||||
MiddleName: | HUSNANDER | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN, CDE | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4387 SW LA PALOMA DR | ||||||||
Address2: |   | ||||||||
City: | PALM CITY | ||||||||
State: | FL | ||||||||
PostalCode: | 349907949 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7722877968 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3441 SE WILLOUGHBY BLVD | ||||||||
Address2: |   | ||||||||
City: | STUART | ||||||||
State: | FL | ||||||||
PostalCode: | 349945060 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7722214030 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/31/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN3191892 | FL | Y |   | Nursing Service Providers | Registered Nurse |   |
No ID Information.