Provider Demographics
NPI:1730961178
Name:FOWLER, KELLEY NICOLE (NP)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:NICOLE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:115 GRACE THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:MICHIE
Mailing Address - State:TN
Mailing Address - Zip Code:38357-7042
Mailing Address - Country:US
Mailing Address - Phone:731-610-2643
Mailing Address - Fax:731-645-5195
Practice Address - Street 1:270 E COURT AVE
Practice Address - Street 2:
Practice Address - City:SELMER
Practice Address - State:TN
Practice Address - Zip Code:38375-2304
Practice Address - Country:US
Practice Address - Phone:731-645-7932
Practice Address - Fax:731-645-5195
Is Sole Proprietor?:No
Enumeration Date:2023-10-19
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN34876363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner