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 1:2200 TYDD ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-1284
Mailing Address - Country:US
Mailing Address - Phone:707-441-1624
Mailing Address - Fax:707-441-1253
Practice Address - Street 1:2200 TYDD ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-1284
Practice Address - Country:US
Practice Address - Phone:707-441-1624
Practice Address - Fax:707-441-1253
Is Sole Proprietor?:No
Enumeration Date:2010-03-22
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA535288163W00000X
CA22550363L00000X, 363L00000X
OR200940058RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA535288OtherRN LICENSE NUMBER, EXPIRED
CA22550OtherNP
CA22550OtherNP
CA535288OtherRN LICENSE NUMBER, EXPIRED