Provider Demographics
NPI:1215420054
Name:FOWLKES, SHARON ANGELICA (LPN)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:ANGELICA
Last Name:FOWLKES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:SHARON
Other - Middle Name:ANGELICA
Other - Last Name:SPELLMAN, BURKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNA
Mailing Address - Street 1:5812 DUNKIRK ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-3128
Mailing Address - Country:US
Mailing Address - Phone:757-318-8407
Mailing Address - Fax:757-673-3606
Practice Address - Street 1:5812 DUNKIRK ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-3128
Practice Address - Country:US
Practice Address - Phone:757-318-8407
Practice Address - Fax:757-673-3606
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002079887164W00000X
3747P1801X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant