MEDICARE: KATELYN MARIE BOWMAN FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	1020093	TX

General Provider Information

NPI Number	:	1013511005
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATELYN MARIE BOWMAN FNP-C

Provider Business Mailing Address
First Line	:	3107 GREENE AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-2319
Country	:	US
Telephone Number	:	817-439-9539
Fax Number	:

Provider Business Practice Location Address
First Line	:	3107 GREENE AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-2319
Country	:	US
Telephone Number	:	817-439-9539
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2020
Last Update Date	:	11/30/2020

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