1407597255 NPI number — MS. KAITLYN ANN BOWEN LAT, ATC

Table of content: MS. KAITLYN ANN BOWEN LAT, ATC (NPI 1407597255)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407597255 NPI number — MS. KAITLYN ANN BOWEN LAT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOWEN
Provider First Name:
KAITLYN
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LAT, ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407597255
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 FOREST PKWY APT A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALLEY PARK
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63088-1008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-779-3432
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14653 CLAYTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALLWIN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63011-2656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-415-7535
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/05/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  2000026684 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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