Provider Demographics
NPI:1073995999
Name:FOWLER, TRACYE (FNP)
Entity Type:Individual
Prefix:
First Name:TRACYE
Middle Name:
Last Name:FOWLER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3290
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-7290
Mailing Address - Country:US
Mailing Address - Phone:541-963-1967
Mailing Address - Fax:541-963-1837
Practice Address - Street 1:570 S 8TH AVE
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:OR
Practice Address - Zip Code:97827-9726
Practice Address - Country:US
Practice Address - Phone:541-437-2273
Practice Address - Fax:541-437-8585
Is Sole Proprietor?:No
Enumeration Date:2015-06-27
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK89619363LF0000X
OR201804011NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily