Basic Information
| Provider Information | |||||||||
| NPI: | 1437684412 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOWLER | ||||||||
| FirstName: | COLBY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 HANDLEY RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TYRONE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302902178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709975714 | ||||||||
| FaxNumber: | 7709972844 | ||||||||
| Practice Location | |||||||||
| Address1: | 190 HANDLEY RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TYRONE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302902178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709975714 | ||||||||
| FaxNumber: | 7709972844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2017 | ||||||||
| LastUpdateDate: | 04/27/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | RN252055 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
No ID Information.