Provider Demographics
NPI:1407597255
Name:BOWEN, KAITLYN ANN (LAT, ATC)
Entity Type:Individual
Prefix:MS
First Name:KAITLYN
Middle Name:ANN
Last Name:BOWEN
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 FOREST PKWY APT A
Mailing Address - Street 2:
Mailing Address - City:VALLEY PARK
Mailing Address - State:MO
Mailing Address - Zip Code:63088-1008
Mailing Address - Country:US
Mailing Address - Phone:217-779-3432
Mailing Address - Fax:
Practice Address - Street 1:14653 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-2656
Practice Address - Country:US
Practice Address - Phone:314-415-7535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20000266842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer