Provider Demographics
NPI:1316594468
Name:FOWLES CEVA, MICHELLE MAE (NP)
Entity type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:MAE
Last Name:FOWLES CEVA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 N CLAY ST
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-3627
Mailing Address - Country:US
Mailing Address - Phone:920-492-6160
Mailing Address - Fax:
Practice Address - Street 1:622 BODART ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4923
Practice Address - Country:US
Practice Address - Phone:920-437-9773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9463-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily