Healthcare Provider Details

I. General information

NPI: 1205290236
Provider Name (Legal Business Name): SURPRENA FOWLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 04/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E WENDOVER AVE
GREENSBORO NC
27405-6713
US

IV. Provider business mailing address

1005 WILD WOLF DR
GREENSBORO NC
27406-8283
US

V. Phone/Fax

Practice location:
  • Phone: 336-641-3218
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number181533
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: