Healthcare Provider Details

I. General information

NPI: 1245118678
Provider Name (Legal Business Name): KELLY VIKTORIN BOWLEY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2025
Last Update Date: 08/25/2025
Certification Date: 08/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 POPLAR AVE KJANSKYRN@GMAIL.COM
KODIAK AK
99615-9961
US

IV. Provider business mailing address

410 POPLAR AVE KJANSKYRN@GMAIL.COM
KODIAK AK
99615-9961
US

V. Phone/Fax

Practice location:
  • Phone: 281-467-2573
  • Fax:
Mailing address:
  • Phone: 281-467-2573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number689023
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number243998
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: