Provider Demographics
NPI:1902895683
Name:FOWLER, KELLY CARROLL (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:CARROLL
Last Name:FOWLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:CARROLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1345 PLAZA COURT N.
Mailing Address - Street 2:#1A
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-2832
Mailing Address - Country:US
Mailing Address - Phone:303-665-3036
Mailing Address - Fax:303-604-6243
Practice Address - Street 1:8990 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-4537
Practice Address - Country:US
Practice Address - Phone:720-929-1655
Practice Address - Fax:303-604-6243
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO173308363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO81480024Medicaid
C804396Medicare PIN
CO81480024Medicaid