Healthcare Provider Details

I. General information

NPI: 1104754688
Provider Name (Legal Business Name): AMANDA BOWEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MANDI BOWEN

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1408 POMERELLE AVE STE H
BURLEY ID
83318-2068
US

IV. Provider business mailing address

2410 DORCHESTER AVE
BURLEY ID
83318-2526
US

V. Phone/Fax

Practice location:
  • Phone: 208-677-6170
  • Fax:
Mailing address:
  • Phone: 208-312-3207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: