Basic Information
| Provider Information | |||||||||
| NPI: | 1952625881 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOWLER | ||||||||
| FirstName: | VICKIE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3798 JANES RD STE 6 | ||||||||
| Address2: | |||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955214745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078223621 | ||||||||
| FaxNumber: | 7078257753 | ||||||||
| Practice Location | |||||||||
| Address1: | 3798 JANES RD STE 6 | ||||||||
| Address2: | |||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955214745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078223621 | ||||||||
| FaxNumber: | 7078257753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2010 | ||||||||
| LastUpdateDate: | 10/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN00167818 | WA | N | Nursing Service Providers | Registered Nurse | 163W00000X | 535288 | CA | N | Nursing Service Providers | Registered Nurse | 163W00000X | 200940058RN | OR | N | Nursing Service Providers | Registered Nurse | 363L00000X | 22550 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | RN 00167818 | 01 | WA | RN LICENSE NUMBER | OTHER | 200940058RN | 01 | OR | RN LICENSE NUMBER | OTHER | 22550 | 01 | CA | NP | OTHER | 535288 | 01 | CA | RN LICENSE NUMBER, EXPIRED | OTHER |