Provider Demographics
NPI:1346067808
Name:FOWLKES, SHANETTE NETINA
Entity type:Individual
Prefix:
First Name:SHANETTE
Middle Name:NETINA
Last Name:FOWLKES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6258 E 36TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-5809
Mailing Address - Country:US
Mailing Address - Phone:918-406-5914
Mailing Address - Fax:
Practice Address - Street 1:2325 S HARVARD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-3300
Practice Address - Country:US
Practice Address - Phone:918-712-4301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL0067608164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse