Healthcare Provider Details

I. General information

NPI: 1629440516
Provider Name (Legal Business Name): TYESHA BOWEN AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2015
Last Update Date: 04/03/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1691 FORUM PL STE B
WEST PALM BEACH FL
33401-2336
US

IV. Provider business mailing address

276 KENSINGTON WAY
ROYAL PALM BEACH FL
33414-4316
US

V. Phone/Fax

Practice location:
  • Phone: 561-412-8992
  • Fax: 401-238-6057
Mailing address:
  • Phone: 561-412-8992
  • Fax: 401-238-6057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License NumberARNP9358144
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberARNP9358144
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberARNP9358144
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: