Healthcare Provider Details

I. General information

NPI: 1619631124
Provider Name (Legal Business Name): RICHARD EVERETT VOWLES IV PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2021
Last Update Date: 10/28/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

463142 STATE ROAD 200
YULEE FL
32097-5554
US

IV. Provider business mailing address

463142 STATE ROAD 200
YULEE FL
32097-5554
US

V. Phone/Fax

Practice location:
  • Phone: 904-225-8280
  • Fax:
Mailing address:
  • Phone: 904-225-8280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11015856
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: