Provider Demographics
NPI:1043300841
Name:FOWLER, ELLEN JOY (NP)
Entity type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:JOY
Last Name:FOWLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13008
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48901-3008
Mailing Address - Country:US
Mailing Address - Phone:517-364-6253
Mailing Address - Fax:517-364-6204
Practice Address - Street 1:1210 W SAGINAW ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48915-1927
Practice Address - Country:US
Practice Address - Phone:517-364-7575
Practice Address - Fax:517-364-7560
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704092592363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5008761270OtherBCBS INDIVIDUAL PIN
MI0M75980Medicare PIN
MIS71676Medicare UPIN