Provider Demographics
NPI:1871138875
Name:FOWLER, JUSTIN JIMMY (APRN; CNP-F)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:JIMMY
Last Name:FOWLER
Suffix:
Gender:M
Credentials:APRN; CNP-F
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 VICKIE DR
Mailing Address - Street 2:
Mailing Address - City:DEL CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115-3949
Mailing Address - Country:US
Mailing Address - Phone:580-559-6348
Mailing Address - Fax:
Practice Address - Street 1:905 VICKIE DR
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-3949
Practice Address - Country:US
Practice Address - Phone:580-559-6348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK108084363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKF082768098OtherOKLAHOMA DRIVERS LICENSE