Healthcare Provider Details

I. General information

NPI: 1366933467
Provider Name (Legal Business Name): JOHNATHAN FOWLER APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 HOSPITAL RD
WHITESBURG KY
41858-7627
US

IV. Provider business mailing address

240 HOSPITAL RD
WHITESBURG KY
41858-7627
US

V. Phone/Fax

Practice location:
  • Phone: 606-633-2255
  • Fax:
Mailing address:
  • Phone: 606-633-2255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3012257
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: