Provider Demographics
NPI:1487933537
Name:FOWLER, MARY JANE (LPN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 RODESSA RD
Mailing Address - Street 2:
Mailing Address - City:GREECE
Mailing Address - State:NY
Mailing Address - Zip Code:14616-4605
Mailing Address - Country:US
Mailing Address - Phone:585-755-7992
Mailing Address - Fax:
Practice Address - Street 1:181 RODESSA RD
Practice Address - Street 2:
Practice Address - City:GREECE
Practice Address - State:NY
Practice Address - Zip Code:14616-4605
Practice Address - Country:US
Practice Address - Phone:585-755-7992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217801-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse