Healthcare Provider Details

I. General information

NPI: 1477057370
Provider Name (Legal Business Name): MELISSA FOWLER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2018
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 RIVER OAKS DR STE 100
FLOWOOD MS
39232-9564
US

IV. Provider business mailing address

1050 RIVER OAKS DR STE 100
FLOWOOD MS
39232-9564
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-4635
  • Fax: 601-200-4635
Mailing address:
  • Phone: 601-200-4635
  • Fax: 601-200-4742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number874961
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: