Basic Information
| Provider Information | |||||||||
| NPI: | 1003258096 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOWLER | ||||||||
| FirstName: | DAWN | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 89 W COPELAND DR | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328062002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218417550 | ||||||||
| FaxNumber: | 3218418185 | ||||||||
| Practice Location | |||||||||
| Address1: | 89 W COPELAND DR | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328062002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218417550 | ||||||||
| FaxNumber: | 3218418185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2013 | ||||||||
| LastUpdateDate: | 04/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | LG-0000694 | DE | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | LG-0000694 | DE | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | ARNP9267591 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LA2200X | APRN9267591 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 105547300 | 05 | FL | MEDICAID |