Healthcare Provider Details

I. General information

NPI: 1174637896
Provider Name (Legal Business Name): BRENDA FOWLER ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 S PECAN ST
DERMOTT AR
71638-2228
US

IV. Provider business mailing address

PO BOX 100
PORTLAND AR
71663-0100
US

V. Phone/Fax

Practice location:
  • Phone: 870-538-5296
  • Fax: 870-538-3701
Mailing address:
  • Phone: 870-737-2737
  • Fax: 870-737-9780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License NumberA01238
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: