Healthcare Provider Details

I. General information

NPI: 1558857938
Provider Name (Legal Business Name): GERI LYN FOWLER RN, QIDP, QMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2018
Last Update Date: 07/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1199 HARRIS AVE
TAWAS CITY MI
48763-9681
US

IV. Provider business mailing address

1199 HARRIS AVE
TAWAS CITY MI
48763-9681
US

V. Phone/Fax

Practice location:
  • Phone: 989-362-8636
  • Fax: 989-362-7800
Mailing address:
  • Phone: 989-362-8636
  • Fax: 989-362-7800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704306184
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: