Provider Demographics
NPI:1689726838
Name:FOWLER-MCDONALD, MADRE LYNNELLE
Entity Type:Individual
Prefix:MRS
First Name:MADRE
Middle Name:LYNNELLE
Last Name:FOWLER-MCDONALD
Suffix:
Gender:F
Credentials:
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 11091
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-0091
Mailing Address - Country:US
Mailing Address - Phone:919-604-3734
Mailing Address - Fax:919-620-0671
Practice Address - Street 1:615 E LAWSON ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-4533
Practice Address - Country:US
Practice Address - Phone:919-604-3734
Practice Address - Fax:616-620-0671
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC3534376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601596Medicaid