Healthcare Provider Details

I. General information

NPI: 1730961178
Provider Name (Legal Business Name): KELLEY NICOLE FOWLER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2023
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 E COURT AVE
SELMER TN
38375-2304
US

IV. Provider business mailing address

115 GRACE THOMAS RD
MICHIE TN
38357-7042
US

V. Phone/Fax

Practice location:
  • Phone: 731-645-7932
  • Fax: 731-645-5195
Mailing address:
  • Phone: 731-610-2643
  • Fax: 731-645-5195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number34876
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: