Provider Demographics
NPI:1134764608
Name:FOWLER, SHANNON MARIE (NP)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARIE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:HIGGINBOTHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:27717 KOSAR XING
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35613-7606
Mailing Address - Country:US
Mailing Address - Phone:256-777-2620
Mailing Address - Fax:256-265-7017
Practice Address - Street 1:1038 RESEARCH BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-2069
Practice Address - Country:US
Practice Address - Phone:205-379-0174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-08
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL113275163W00000X
TN32107363LF0000X
AL1-113275363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1134764608Medicaid