Healthcare Provider Details

I. General information

NPI: 1316594468
Provider Name (Legal Business Name): MICHELLE MAE FOWLES CEVA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2019
Last Update Date: 08/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 BODART ST
GREEN BAY WI
54301-4923
US

IV. Provider business mailing address

825 N CLAY ST
DE PERE WI
54115-3627
US

V. Phone/Fax

Practice location:
  • Phone: 920-437-9773
  • Fax:
Mailing address:
  • Phone: 920-492-6160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9463-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: