Healthcare Provider Details

I. General information

NPI: 1922799253
Provider Name (Legal Business Name): ELIZABETH A BOWEN RN, ACCNS-AG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 05/17/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1239 E MAIN ST
CARBONDALE IL
62901-3175
US

IV. Provider business mailing address

1239 E MAIN ST
CARBONDALE IL
62901-3175
US

V. Phone/Fax

Practice location:
  • Phone: 618-457-5200
  • Fax:
Mailing address:
  • Phone: 618-457-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number209022957
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041344271
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: