Healthcare Provider Details

I. General information

NPI: 1578933784
Provider Name (Legal Business Name): STACIE BOWKETT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 EISENHOWER DR
SAVANNAH GA
31406-5027
US

IV. Provider business mailing address

1915 EISENHOWER DR
SAVANNAH GA
31406-5027
US

V. Phone/Fax

Practice location:
  • Phone: 912-356-2012
  • Fax:
Mailing address:
  • Phone: 912-356-2012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number060738-21
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN240129
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN240129
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: