MEDICARE: MISS MICHELLE MAE FOWLES CEVA NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	9463-33	WI

General Provider Information

NPI Number	:	1316594468
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MICHELLE MAE FOWLES CEVA NP

Provider Business Mailing Address
First Line	:	825 N CLAY ST
Second Line	:
City	:	DE PERE
State	:	WI
Zip	:	54115-3627
Country	:	US
Telephone Number	:	920-492-6160
Fax Number	:

Provider Business Practice Location Address
First Line	:	622 BODART ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54301-4923
Country	:	US
Telephone Number	:	920-437-9773
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2019
Last Update Date	:	08/23/2019

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