Provider Demographics
NPI:1740155183
Name:BOWEN, KISHA L
Entity type:Individual
Prefix:
First Name:KISHA
Middle Name:L
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 1:1234 S 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-1830
Mailing Address - Country:US
Mailing Address - Phone:708-670-2835
Mailing Address - Fax:
Practice Address - Street 1:1234 S 13TH AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-1830
Practice Address - Country:US
Practice Address - Phone:708-670-2835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-07
Last Update Date:2025-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.032790363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner