Provider Demographics
NPI:1043556434
Name:FOWLER, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:FOWLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 W GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:NY
Mailing Address - Zip Code:14433-1126
Mailing Address - Country:US
Mailing Address - Phone:315-923-3640
Mailing Address - Fax:
Practice Address - Street 1:4 WEST GENESEE STREET
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:NY
Practice Address - Zip Code:14433
Practice Address - Country:US
Practice Address - Phone:315-923-3640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-12
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF337382-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily