Provider Demographics
NPI:1740783216
Name:BOWLER, LATREICE MONAE
Entity Type:Individual
Prefix:
First Name:LATREICE
Middle Name:MONAE
Last Name:BOWLER
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 1:3231 S GULLEY RD STE E
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-4407
Mailing Address - Country:US
Mailing Address - Phone:313-278-2327
Mailing Address - Fax:
Practice Address - Street 1:620 GERMANTOWN PIKE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE HILL
Practice Address - State:PA
Practice Address - Zip Code:19444-1810
Practice Address - Country:US
Practice Address - Phone:313-278-2327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
MI247000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other