Provider Demographics
NPI:1225819394
Name:FOWLER, TANYA L (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:L
Last Name:FOWLER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:554 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-3160
Mailing Address - Country:US
Mailing Address - Phone:910-388-4716
Mailing Address - Fax:
Practice Address - Street 1:313 WALNUT ST STE 110
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-4063
Practice Address - Country:US
Practice Address - Phone:910-668-0268
Practice Address - Fax:910-446-8622
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-13
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC193358363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health