Healthcare Provider Details

I. General information

NPI: 1649942236
Provider Name (Legal Business Name): TERESA FOWLER DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 10/01/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 SKYLINE DR
JACKSON TN
38301-3923
US

IV. Provider business mailing address

1581 CUFF RD
CAMDEN TN
38320
US

V. Phone/Fax

Practice location:
  • Phone: 731-541-5000
  • Fax:
Mailing address:
  • Phone: 731-441-1838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number30267
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number30267
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: