Provider Demographics
NPI:1215115852
Name:BOWEN, STACEA N (MD)
Entity type:Individual
Prefix:
First Name:STACEA
Middle Name:N
Last Name:BOWEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 S STATE ROAD 7
Mailing Address - Street 2:SUITE 450
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-9325
Mailing Address - Country:US
Mailing Address - Phone:561-798-1233
Mailing Address - Fax:561-798-1655
Practice Address - Street 1:1395 S STATE ROAD 7
Practice Address - Street 2:SUITE 450
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-9325
Practice Address - Country:US
Practice Address - Phone:561-798-1233
Practice Address - Fax:561-798-1655
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT185830207V00000X
FLME107910207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003286400Medicaid
FLDS289ZMedicare PIN