Healthcare Provider Details

I. General information

NPI: 1134764608
Provider Name (Legal Business Name): SHANNON MARIE FOWLER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON MARIE HIGGINBOTHAM

II. Dates (important events)

Enumeration Date: 11/08/2019
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1038 RESEARCH BLVD
MADISON AL
35758-2069
US

IV. Provider business mailing address

27717 KOSAR XING
ATHENS AL
35613-7606
US

V. Phone/Fax

Practice location:
  • Phone: 205-379-0174
  • Fax:
Mailing address:
  • Phone: 256-777-2620
  • Fax: 256-265-7017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number113275
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number32107
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1-113275
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: