Provider Demographics
NPI:1639195878
Name:BOWER, BONNIE D (NP-C)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:D
Last Name:BOWER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E. WOODROW WILSON DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-362-4471
Mailing Address - Fax:
Practice Address - Street 1:1500 E. WOODROW WILSON DR.
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5199
Practice Address - Country:US
Practice Address - Phone:601-364-1358
Practice Address - Fax:601-364-1357
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR662828363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06785339Medicaid
MSQ53657Medicare UPIN