Provider Demographics
NPI:1861403271
Name:FOWLER, JEANA KELLY (RN/ADM)
Entity type:Individual
Prefix:
First Name:JEANA
Middle Name:KELLY
Last Name:FOWLER
Suffix:
Gender:F
Credentials:RN/ADM
Other - Prefix:
Other - First Name:JEANA
Other - Middle Name:KELLY
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN/DON
Mailing Address - Street 1:3329 WOOTEN RD
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:OK
Mailing Address - Zip Code:74633
Mailing Address - Country:US
Mailing Address - Phone:918-287-7279
Mailing Address - Fax:918-287-5572
Practice Address - Street 1:1449 W MAIN
Practice Address - Street 2:
Practice Address - City:PAWHUSKA
Practice Address - State:OK
Practice Address - Zip Code:74056
Practice Address - Country:US
Practice Address - Phone:918-287-5645
Practice Address - Fax:918-287-5572
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKD6079682163WA2000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163WA2000XNursing Service ProvidersRegistered NurseAdministrator
Not Answered163WH0200XNursing Service ProvidersRegistered NurseHome Health