Healthcare Provider Details

I. General information

NPI: 1922493659
Provider Name (Legal Business Name): MISS STEPHANIE ROXIE FOWLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2015
Last Update Date: 03/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 CARLYLE CLOSE APT 1050
MOBILE AL
36609-1873
US

IV. Provider business mailing address

3701 CARLYLE CLOSE APT 1050
MOBILE AL
36609-1873
US

V. Phone/Fax

Practice location:
  • Phone: 334-300-1942
  • Fax:
Mailing address:
  • Phone: 334-300-1942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberS10746
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: