Provider Demographics
NPI:1912195538
Name:FOWLER, BONITA S (C-FNP)
Entity Type:Individual
Prefix:
First Name:BONITA
Middle Name:S
Last Name:FOWLER
Suffix:
Gender:F
Credentials:C-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 CHERRY ST
Mailing Address - Street 2:BUILDING I
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-3341
Mailing Address - Country:US
Mailing Address - Phone:304-324-2715
Mailing Address - Fax:304-324-2774
Practice Address - Street 1:512 CHERRY ST
Practice Address - Street 2:BUILDING I
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-3341
Practice Address - Country:US
Practice Address - Phone:304-324-2715
Practice Address - Fax:304-324-2774
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV39884363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner