Provider Demographics
NPI:1922607548
Name:HAMILTON, BRECK FOWLER
Entity Type:Individual
Prefix:
First Name:BRECK
Middle Name:FOWLER
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRECK
Other - Middle Name:
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3520 US HIGHWAY 431 STE 200
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35950-0081
Mailing Address - Country:US
Mailing Address - Phone:256-849-0500
Mailing Address - Fax:
Practice Address - Street 1:3520 US HIGHWAY 431 STE 200
Practice Address - Street 2:
Practice Address - City:ALBERTVILLE
Practice Address - State:AL
Practice Address - Zip Code:35950-0081
Practice Address - Country:US
Practice Address - Phone:256-840-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-24
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-169321163W00000X
ALAG10220131363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse