Healthcare Provider Details

I. General information

NPI: 1609791565
Provider Name (Legal Business Name): HALEY BRIANNE FOWLER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 COLONY DR
ADA OK
74820-2329
US

IV. Provider business mailing address

527 W 3RD ST
KONAWA OK
74849-1415
US

V. Phone/Fax

Practice location:
  • Phone: 580-436-5111
  • Fax:
Mailing address:
  • Phone: 580-436-5111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number229820
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: