Provider Demographics
NPI:1477839579
Name:BOWEN, MIRANDA NICOLE
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:NICOLE
Last Name:BOWEN
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 1:610 E 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99501-2731
Mailing Address - Country:US
Mailing Address - Phone:907-258-3498
Mailing Address - Fax:907-222-4796
Practice Address - Street 1:9907 POSEIDON DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-4508
Practice Address - Country:US
Practice Address - Phone:907-301-7020
Practice Address - Fax:907-222-1230
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1009140171M00000X
AK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator