Provider Demographics
NPI:1114586658
Name:BOWMAN, LATONYA R (LMBT)
Entity Type:Individual
Prefix:MS
First Name:LATONYA
Middle Name:R
Last Name:BOWMAN
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3111 WINDSHIRE LN APT 204
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-4173
Mailing Address - Country:US
Mailing Address - Phone:704-449-7104
Mailing Address - Fax:
Practice Address - Street 1:10000 BALLANTYNE COMMONS PKWY
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-2484
Practice Address - Country:US
Practice Address - Phone:704-449-7104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-09
Last Update Date:2019-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6476225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty