Individual
JUSTIN JIMMY FOWLER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
APRN; CNP-F
Contact information
Practice address
905 VICKIE DR, DEL CITY, OK 73115-3949
(580) 559-6348
Mailing address
905 VICKIE DR, DEL CITY, OK 73115-3949
(580) 559-6348
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
108084
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
F082768098
OKLAHOMA DRIVERS LICENSE
OK
Enumeration date
11/13/2019
Last updated
11/13/2019
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