Provider Demographics
NPI:1831972017
Name:FOWLER, MELISSA (FNP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:FOWLER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 COUNTRY CREEK RD NE
Mailing Address - Street 2:
Mailing Address - City:WHITE
Mailing Address - State:GA
Mailing Address - Zip Code:30184-2815
Mailing Address - Country:US
Mailing Address - Phone:678-899-8471
Mailing Address - Fax:
Practice Address - Street 1:4477 TOWNE LAKE PKWY STE 130
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-6720
Practice Address - Country:US
Practice Address - Phone:770-249-5620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN230583363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty