Provider Demographics
NPI:1952625881
Name:FOWLER, VICKIE LYNN (NP)
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:LYNN
Last Name:FOWLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3798 JANES RD STE 6
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-4745
Mailing Address - Country:US
Mailing Address - Phone:707-822-3621
Mailing Address - Fax:707-825-7753
Practice Address - Street 1:3798 JANES RD STE 6
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-4745
Practice Address - Country:US
Practice Address - Phone:707-822-3621
Practice Address - Fax:707-825-7753
Is Sole Proprietor?:No
Enumeration Date:2010-03-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00167818163W00000X
CA535288163W00000X
OR200940058RN163W00000X
CA22550363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WARN 00167818OtherRN LICENSE NUMBER
OR200940058RNOtherRN LICENSE NUMBER
CA22550OtherNP
CA535288OtherRN LICENSE NUMBER, EXPIRED