Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225400000X | Rehabilitation Practitioner | CA |
NPI | 1003320342 |
---|---|
Provider Name | Staci Nicole Bowie |
First Address | North Hills, CA 91343-5117 |
Second Address | Lancaster, CA 93535-4089 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/11/2017 |
Last Update Date | 11/04/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
95-2633765 | MEDI-CAL (01) | CA |