Provider Demographics
NPI:1336690411
Name:FOWLER, MARTHA JOANNA (FNP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:JOANNA
Last Name:FOWLER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:JOANNA
Other - Last Name:COCKING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:5 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611-4215
Practice Address - Country:US
Practice Address - Phone:864-220-7270
Practice Address - Fax:864-241-9211
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20291363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP4245Medicaid