Provider Demographics
NPI:1417587726
Name:BOWMAN, DEIDRE LANAE (COSMETOLOGIST)
Entity Type:Individual
Prefix:MRS
First Name:DEIDRE
Middle Name:LANAE
Last Name:BOWMAN
Suffix:
Gender:F
Credentials:COSMETOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2804 CARVER RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21225-1312
Mailing Address - Country:US
Mailing Address - Phone:443-673-7064
Mailing Address - Fax:
Practice Address - Street 1:5441 BALTIMORE NATIONAL PIKE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-2102
Practice Address - Country:US
Practice Address - Phone:443-673-7064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-26
Last Update Date:2020-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD4528041744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty