Provider Demographics
NPI:1558390559
Name:FOWLER, KRISTA M (APRN)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:M
Last Name:FOWLER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-331-3353
Mailing Address - Fax:859-331-3326
Practice Address - Street 1:711 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017
Practice Address - Country:US
Practice Address - Phone:859-331-3353
Practice Address - Fax:859-331-3326
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3003874363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000262563OtherANTHEM PIN
IN200459810AMedicaid
KY7100103540Medicaid
KYP00912933OtherRAILROAD MEDICARE
OH3030562Medicaid
KY7100103540Medicaid
KY0713005Medicare PIN
OH3030562Medicaid
KY500028593Medicare PIN
KY0259833Medicare PIN
KYP00912933OtherRAILROAD MEDICARE
KY1271841Medicare PIN
KY0558413Medicare PIN
KY0558313Medicare PIN
KYP71760Medicare UPIN