Provider Demographics
NPI:1700663879
Name:FOWLKES, TRESSIE (BA)
Entity Type:Individual
Prefix:
First Name:TRESSIE
Middle Name:
Last Name:FOWLKES
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 UNION STATION DRIVE, FORT WAYNE, IN, USA
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814
Mailing Address - Country:US
Mailing Address - Phone:678-815-5395
Mailing Address - Fax:
Practice Address - Street 1:707 UNION STATION DRIVE, FORT WAYNE, IN, USA
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46814
Practice Address - Country:US
Practice Address - Phone:678-815-5395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty