Provider Demographics
NPI:1043634199
Name:BOWEN, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
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 1:4015 MCDONALD RD
Mailing Address - Street 2:
Mailing Address - City:APISON
Mailing Address - State:TN
Mailing Address - Zip Code:37302-9575
Mailing Address - Country:US
Mailing Address - Phone:423-991-1199
Mailing Address - Fax:
Practice Address - Street 1:365 MONTAUK AVE
Practice Address - Street 2:LAWRENCE AND MEMORIAL HOSPITAL
Practice Address - City:NEW LONDON
Practice Address - State:TN
Practice Address - Zip Code:06320
Practice Address - Country:US
Practice Address - Phone:860-442-0711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12.00 5672363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health