Provider Demographics
NPI:1255848008
Name:BOWICK, VANITA ANDREA
Entity Type:Individual
Prefix:
First Name:VANITA
Middle Name:ANDREA
Last Name:BOWICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 HARRISON AVE APT G7
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4564
Mailing Address - Country:US
Mailing Address - Phone:850-688-5244
Mailing Address - Fax:
Practice Address - Street 1:2121 HARRISON AVE APT G7
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4564
Practice Address - Country:US
Practice Address - Phone:850-688-5244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL234759376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020363100Medicaid
FL022663400Medicaid