Healthcare Provider Details

I. General information

NPI: 1417587726
Provider Name (Legal Business Name): DEIDRE LANAE BOWMAN COSMETOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2020
Last Update Date: 01/26/2020
Certification Date: 01/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5441 BALTIMORE NATIONAL PIKE
BALTIMORE MD
21229-2102
US

IV. Provider business mailing address

2804 CARVER RD
BALTIMORE MD
21225-1312
US

V. Phone/Fax

Practice location:
  • Phone: 443-673-7064
  • Fax:
Mailing address:
  • Phone: 443-673-7064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number452804
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: