Healthcare Provider Details

I. General information

NPI: 1386197697
Provider Name (Legal Business Name): SCOTT FOWLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2016
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 S 11TH AVE
LAUREL MS
39440-4312
US

IV. Provider business mailing address

1093 NAQUIN RD
PURVIS MS
39475-6051
US

V. Phone/Fax

Practice location:
  • Phone: 601-425-3033
  • Fax: 601-422-0431
Mailing address:
  • Phone: 601-520-3982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number901535
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: