Provider Demographics
NPI:1194830257
Name:FOWLKES, MELODY A (APNP)
Entity Type:Individual
Prefix:MS
First Name:MELODY
Middle Name:A
Last Name:FOWLKES
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12122 N ROLLING FIELD DR
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53097-2766
Mailing Address - Country:US
Mailing Address - Phone:262-242-2283
Mailing Address - Fax:262-242-2156
Practice Address - Street 1:12122 N ROLLING FIELD DR
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-2766
Practice Address - Country:US
Practice Address - Phone:262-242-2283
Practice Address - Fax:262-242-2156
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI80518-030363L00000X
WI1462-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner