Provider Demographics
NPI:1336553338
Name:FOWLER, VINNETTE
Entity Type:Individual
Prefix:
First Name:VINNETTE
Middle Name:
Last Name:FOWLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 N TERRACE AVE
Mailing Address - Street 2:APT. 2
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10552-3158
Mailing Address - Country:US
Mailing Address - Phone:914-912-6562
Mailing Address - Fax:
Practice Address - Street 1:539 N TERRACE AVE
Practice Address - Street 2:APT. 2
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10552-3158
Practice Address - Country:US
Practice Address - Phone:914-912-6562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305250164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse