Healthcare Provider Details

I. General information

NPI: 1093845455
Provider Name (Legal Business Name): LADONNA RENAE BOWLING DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LADONNA RENAE WOLFE DO

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 02/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12301 GRAPEFIELD RD
BASTIAN VA
24314-4547
US

IV. Provider business mailing address

12301 GRAPEFIELD RD
BASTIAN VA
24314-4547
US

V. Phone/Fax

Practice location:
  • Phone: 276-688-4331
  • Fax: 276-688-4336
Mailing address:
  • Phone: 276-688-4331
  • Fax: 276-688-4336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2128
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102203420
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: