Provider Demographics
NPI:1811422462
Name:BOWEN, TRACI D
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:D
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 1:4600 DUPREE RD
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-8680
Mailing Address - Country:US
Mailing Address - Phone:662-772-6417
Mailing Address - Fax:
Practice Address - Street 1:4600 DUPREE RD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-8680
Practice Address - Country:US
Practice Address - Phone:662-772-6417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide