Healthcare Provider Details

I. General information

NPI: 1962081513
Provider Name (Legal Business Name): JUNETTA NUCKELS BOWEN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JUNETTA PAIGE NUCKELS D.O.

II. Dates (important events)

Enumeration Date: 04/02/2021
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 MARKET ST
NORTH TAZEWELL VA
24630-5016
US

IV. Provider business mailing address

213 S JEFFERSON ST STE 1006
ROANOKE VA
24011-1713
US

V. Phone/Fax

Practice location:
  • Phone: 276-988-8850
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102208777
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: