=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649598749
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLIE LYNN BOWHALL LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2010
-----------------------------------------------------
Last Update Date | 09/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 650 STATE ST
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13601-2839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-755-1251
-----------------------------------------------------
Fax | 315-291-6601
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34048 ANTWERP ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13673-4106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-704-6110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 55304
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 277760
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------