Provider Demographics
NPI:1992915052
Name:FOWERS, JODY LYNN (FNP)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:LYNN
Last Name:FOWERS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 281221
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1221
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2950 N CHURCH ST STE 200
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84040-6590
Practice Address - Country:US
Practice Address - Phone:801-771-7700
Practice Address - Fax:801-771-7799
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT263957-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1992915052Medicaid
UT000066707Medicare PIN
UT1992915052Medicaid
P00796430Medicare PIN
P00749025Medicare PIN