Healthcare Provider Details

I. General information

NPI: 1467665919
Provider Name (Legal Business Name): ANNETTE JEAN BOWERSOX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1399 JENNY ROAD
MALVERN AK
72104
US

IV. Provider business mailing address

1399 JENNY ROAD
MALVERN AK
72104
US

V. Phone/Fax

Practice location:
  • Phone: 501-337-7882
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberR52673
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: