Healthcare Provider Details

I. General information

NPI: 1386912939
Provider Name (Legal Business Name): CARLA J FOWLER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2011
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10382 AUGUSTA DR
SAUK CENTRE MN
56378-4864
US

IV. Provider business mailing address

460 RIVER ST W
HOLDINGFORD MN
56340-4519
US

V. Phone/Fax

Practice location:
  • Phone: 320-351-8422
  • Fax:
Mailing address:
  • Phone: 320-248-2904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR160100-0
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number112
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: