Provider Demographics
NPI:1083276729
Name:FOWLER, MICHELLE MARIE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MARIE
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:N9720 STATE ROAD 49
Mailing Address - Street 2:
Mailing Address - City:IOLA
Mailing Address - State:WI
Mailing Address - Zip Code:54945-9286
Mailing Address - Country:US
Mailing Address - Phone:414-418-0489
Mailing Address - Fax:
Practice Address - Street 1:15 6TH ST
Practice Address - Street 2:
Practice Address - City:CLINTONVILLE
Practice Address - State:WI
Practice Address - Zip Code:54929-1624
Practice Address - Country:US
Practice Address - Phone:920-851-8051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30768-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse