Provider Demographics
NPI:1043412695
Name:FOWLER, AMANDA C (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:C
Last Name:FOWLER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:C
Other - Last Name:VAUGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1315 ROBERTS STREET
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020-3737
Mailing Address - Country:US
Mailing Address - Phone:803-432-4311
Mailing Address - Fax:910-715-1926
Practice Address - Street 1:1315 ROBERTS STREET
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-3737
Practice Address - Country:US
Practice Address - Phone:803-432-4311
Practice Address - Fax:910-715-1943
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC89111367500000X
SC077506367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN1684Medicaid
SC89111OtherRN LICENSE
SCQ347493410Medicare PIN