Provider Demographics
NPI:1508472382
Name:BOWEN, KELLY EILEEN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:EILEEN
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 1:12409 W PALO VERDE DR
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-3801
Mailing Address - Country:US
Mailing Address - Phone:480-274-5264
Mailing Address - Fax:
Practice Address - Street 1:19420 N 59TH AVE STE H830
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6980
Practice Address - Country:US
Practice Address - Phone:623-302-9020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer