Basic Information
| Provider Information | |||||||||
| NPI: | 1598339699 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOWLIN | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | YANCEY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1022 VIRGINIA AVE | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 239279035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4342100743 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3762 DURHAM RD STE B | ||||||||
| Address2: | |||||||||
| City: | ROXBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275732741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4344473151 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2021 | ||||||||
| LastUpdateDate: | 09/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 0024181357 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 5014976 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.