Provider Demographics
NPI:1174637896
Name:FOWLER, BRENDA (ANP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:FOWLER
Suffix:
Gender:F
Credentials:ANP
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 100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:AR
Mailing Address - Zip Code:71663-0100
Mailing Address - Country:US
Mailing Address - Phone:870-737-2737
Mailing Address - Fax:870-737-9780
Practice Address - Street 1:604 S PECAN ST
Practice Address - Street 2:
Practice Address - City:DERMOTT
Practice Address - State:AR
Practice Address - Zip Code:71638-2228
Practice Address - Country:US
Practice Address - Phone:870-538-5296
Practice Address - Fax:870-538-3701
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01238363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5S843Medicare ID - Type Unspecified