Provider Demographics
NPI:1558055079
Name:FOWLER, MARIBEL BERENICE (NP)
Entity Type:Individual
Prefix:
First Name:MARIBEL
Middle Name:BERENICE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARIBEL
Other - Middle Name:BERENICE
Other - Last Name:CHAVEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:240 S CAVE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-8205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2651 E DISCOVERY PKWY
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-9059
Practice Address - Country:US
Practice Address - Phone:812-353-5252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-07
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28281613A163W00000X
IN71014311A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse