Provider Demographics
NPI:1952698045
Name:FOWLER, COLEATHA ZELDA (FNP)
Entity Type:Individual
Prefix:
First Name:COLEATHA
Middle Name:ZELDA
Last Name:FOWLER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:COLELEETHER
Other - Middle Name:ZELDA
Other - Last Name:FOWLER-WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 395
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70722-0395
Mailing Address - Country:US
Mailing Address - Phone:225-683-5292
Mailing Address - Fax:225-683-3411
Practice Address - Street 1:9001 SUMMA AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3726
Practice Address - Country:US
Practice Address - Phone:225-761-5200
Practice Address - Fax:225-761-5425
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06599363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01626764Medicaid
LA2158333Medicaid
MS01626764Medicaid