Provider Demographics
NPI:1962081513
Name:BOWEN, JUNETTA NUCKELS (DO)
Entity type:Individual
Prefix:
First Name:JUNETTA
Middle Name:NUCKELS
Last Name:BOWEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JUNETTA
Other - Middle Name:PAIGE
Other - Last Name:NUCKELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:388 BEN BOLT AVE
Practice Address - Street 2:
Practice Address - City:TAZEWELL
Practice Address - State:VA
Practice Address - Zip Code:24651-5386
Practice Address - Country:US
Practice Address - Phone:276-988-8850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0102208777207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program