Healthcare Provider Details

I. General information

NPI: 1972526523
Provider Name (Legal Business Name): JERALD LEE COWLES RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 BAY PINES BLVD
ST. PETERSBURG FL
33710
US

IV. Provider business mailing address

771 63RD AVE N
ST PETERSBURG FL
33702-6605
US

V. Phone/Fax

Practice location:
  • Phone: 727-398-9389
  • Fax:
Mailing address:
  • Phone: 727-527-8956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number679442
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: