Provider Demographics
NPI:1760688824
Name:FOWLER, NANCY CHRISTINE (APRN, BC, CNP)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:CHRISTINE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:APRN, BC, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5207 S BLACKSTONE AVE
Mailing Address - Street 2:APT #2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4126
Mailing Address - Country:US
Mailing Address - Phone:773-363-6398
Mailing Address - Fax:773-363-7933
Practice Address - Street 1:1725 W HARRISON ST
Practice Address - Street 2:SUITE 110
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-829-8021
Practice Address - Fax:312-829-1476
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213291Medicare ID - Type Unspecified
ILQ67201Medicare UPIN