Healthcare Provider Details

I. General information

NPI: 1538422100
Provider Name (Legal Business Name): MS. MELISSA DAWN FOWLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 MUSKET CT
SIMPSONVILLE SC
29680-7232
US

IV. Provider business mailing address

4 MUSKET CT
SIMPSONVILLE SC
29680-7232
US

V. Phone/Fax

Practice location:
  • Phone: 864-399-9336
  • Fax:
Mailing address:
  • Phone: 864-399-9336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SH0200X
TaxonomyHome Health Clinical Nurse Specialist
License Number154486E
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number154886E
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number154886E
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code224ZF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapy Assistant
License Number154886E
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: