=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205476868
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOWSERS GARDEN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2020
-----------------------------------------------------
Last Update Date | 09/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2400 W DUNLAP AVE STE 125
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85021-2885
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-803-7016
-----------------------------------------------------
Fax | 623-738-4025
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2400 W DUNLAP AVE STE 125
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85021-2885
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-803-7016
-----------------------------------------------------
Fax | 623-738-4025
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO, DNP
-----------------------------------------------------
Name | LUANNE TAKACS KELLY
-----------------------------------------------------
Credential | DNP, ANP-BC, MBA
-----------------------------------------------------
Telephone | 480-803-7016
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------