Provider Demographics
NPI:1821287236
Name:BOWEN, ELENA (LMT)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:BOWEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18942 DALE MABRY HWY N
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-4907
Mailing Address - Country:US
Mailing Address - Phone:813-909-0961
Mailing Address - Fax:813-909-2086
Practice Address - Street 1:18942 DALE MABRY HWY N
Practice Address - Street 2:SUITE 102
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-4907
Practice Address - Country:US
Practice Address - Phone:813-909-0961
Practice Address - Fax:813-909-2086
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA49885174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA49885OtherFLORIDA LICENSE