Provider Demographics
NPI:1740852045
Name:GOWEN, VARVARA SELIUTINA
Entity type:Individual
Prefix:MRS
First Name:VARVARA
Middle Name:SELIUTINA
Last Name:GOWEN
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 1:3237 EL VALLE WAY
Mailing Address - Street 2:
Mailing Address - City:ANTELOPE
Mailing Address - State:CA
Mailing Address - Zip Code:95843-4972
Mailing Address - Country:US
Mailing Address - Phone:916-532-1118
Mailing Address - Fax:
Practice Address - Street 1:2377 GOLD MEADOW WAY STE 100
Practice Address - Street 2:
Practice Address - City:GOLD RIVER
Practice Address - State:CA
Practice Address - Zip Code:95670-4444
Practice Address - Country:US
Practice Address - Phone:916-965-4012
Practice Address - Fax:916-965-1082
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-15
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86089686133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered