Provider Demographics
NPI:1477057370
Name:FOWLER, MELISSA (FNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:FOWLER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 RIVER OAKS DR STE 100
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9564
Mailing Address - Country:US
Mailing Address - Phone:601-200-4635
Mailing Address - Fax:601-200-4742
Practice Address - Street 1:1050 RIVER OAKS DR STE 100
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9564
Practice Address - Country:US
Practice Address - Phone:601-200-4635
Practice Address - Fax:601-200-4635
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS874961363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS008738867Medicaid