Provider Demographics
NPI:1386912939
Name:FOWLER, CARLA J (CRNA)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:J
Last Name:FOWLER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 RIVER ST W
Mailing Address - Street 2:
Mailing Address - City:HOLDINGFORD
Mailing Address - State:MN
Mailing Address - Zip Code:56340-4519
Mailing Address - Country:US
Mailing Address - Phone:320-248-2904
Mailing Address - Fax:
Practice Address - Street 1:10382 AUGUSTA DR
Practice Address - Street 2:
Practice Address - City:SAUK CENTRE
Practice Address - State:MN
Practice Address - Zip Code:56378-4864
Practice Address - Country:US
Practice Address - Phone:320-351-8422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-11
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR160100-0367500000X
MN112367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered