Healthcare Provider Details

I. General information

NPI: 1861403271
Provider Name (Legal Business Name): JEANA KELLY FOWLER RN/ADM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JEANA KELLY SMITH RN/DON

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1449 W MAIN
PAWHUSKA OK
74056
US

IV. Provider business mailing address

3329 WOOTEN RD
BURBANK OK
74633
US

V. Phone/Fax

Practice location:
  • Phone: 918-287-5645
  • Fax: 918-287-5572
Mailing address:
  • Phone: 918-287-7279
  • Fax: 918-287-5572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberD6079682
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberD6079682
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: