Healthcare Provider Details

I. General information

NPI: 1124378807
Provider Name (Legal Business Name): TERESA M BOWMAN IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2012
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 WILLOW WAY
SAINT CHARLES MO
63304-7223
US

IV. Provider business mailing address

18 WILLOW WAY
SAINT CHARLES MO
63304-7223
US

V. Phone/Fax

Practice location:
  • Phone: 314-603-0873
  • Fax:
Mailing address:
  • Phone: 314-603-0873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number11114691
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: