Provider Demographics
NPI:1033502463
Name:FOWLER, MISTY (LPN)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:FOWLER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3775 US HIGHWAY 40 SW
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:OH
Mailing Address - Zip Code:43140-9776
Mailing Address - Country:US
Mailing Address - Phone:740-506-3782
Mailing Address - Fax:
Practice Address - Street 1:3775 US HIGHWAY 40 SW
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:OH
Practice Address - Zip Code:43140
Practice Address - Country:US
Practice Address - Phone:740-506-3782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-10
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-153428-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse