Healthcare Provider Details

I. General information

NPI: 1649828120
Provider Name (Legal Business Name): MS. DARETH ELIZABETH FOWLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 DEERFIELD TRL
SPRINGFIELD OH
45503-7445
US

IV. Provider business mailing address

709 DEERFIELD TRL
SPRINGFIELD OH
45503-7445
US

V. Phone/Fax

Practice location:
  • Phone: 614-746-0440
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN.NP.024987
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN.NP.024987
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: