Provider Demographics
NPI:1033799564
Name:FOWLER, DESTINEE BRIANA (PA-C)
Entity Type:Individual
Prefix:
First Name:DESTINEE
Middle Name:BRIANA
Last Name:FOWLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DESTINEE
Other - Middle Name:BRIANA
Other - Last Name:HAGAMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:745 TRACY LN UNIT 113
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-0064
Mailing Address - Country:US
Mailing Address - Phone:302-399-5907
Mailing Address - Fax:
Practice Address - Street 1:1492 TINY TOWN RD STE A1-A2
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-7873
Practice Address - Country:US
Practice Address - Phone:615-553-5000
Practice Address - Fax:615-758-3875
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-09
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4534363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty