Healthcare Provider Details

I. General information

NPI: 1720794126
Provider Name (Legal Business Name): BRANDEE M FOWLER MS, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 HARRISON STREET
BATESVILLE AR
72501
US

IV. Provider business mailing address

20 CANTERBURY CIR
BATESVILLE AR
72501
US

V. Phone/Fax

Practice location:
  • Phone: 870-262-1291
  • Fax:
Mailing address:
  • Phone: 479-970-9679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1161
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: