Provider Demographics
NPI:1780208751
Name:FOWKE, MICHELLE K (SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:K
Last Name:FOWKE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6555 QUINCE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-8202
Mailing Address - Country:US
Mailing Address - Phone:901-515-5900
Mailing Address - Fax:901-515-5949
Practice Address - Street 1:6555 QUINCE RD STE 200
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-8202
Practice Address - Country:US
Practice Address - Phone:901-515-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2572235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist