Healthcare Provider Details

I. General information

NPI: 1285730317
Provider Name (Legal Business Name): SANDRA JEAN BOWE LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S MAIN ST
MONTESANO WA
98563-3709
US

IV. Provider business mailing address

PO BOX 828
MONTESANO WA
98563-0828
US

V. Phone/Fax

Practice location:
  • Phone: 360-249-2097
  • Fax: 360-249-2591
Mailing address:
  • Phone: 360-249-2097
  • Fax: 360-249-2591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00017463
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: