Provider Demographics
NPI:1629634902
Name:BOWEN, JACQUANISHA (FNP)
Entity Type:Individual
Prefix:
First Name:JACQUANISHA
Middle Name:
Last Name:BOWEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6045 OLD PLANK RD
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265-3107
Mailing Address - Country:US
Mailing Address - Phone:336-501-0045
Mailing Address - Fax:
Practice Address - Street 1:6045 OLD PLANK RD
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-3107
Practice Address - Country:US
Practice Address - Phone:336-501-0045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCF03190083363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCF03190083OtherAANP