Healthcare Provider Details

I. General information

NPI: 1548200116
Provider Name (Legal Business Name): MARIECKEN FOWLER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11215 METRO PKWY STE 1
FORT MYERS FL
33966-1206
US

IV. Provider business mailing address

11215 METRO PKWY BLDG 3
FORT MYERS FL
33966-1206
US

V. Phone/Fax

Practice location:
  • Phone: 239-208-2212
  • Fax:
Mailing address:
  • Phone: 239-208-2212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number0101238278
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2084D0003X
TaxonomyDiagnostic Neuroimaging (Psychiatry & Neurology) Physician
License Number0101238278
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2020035640
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number20637
License Number StateNH
# 5
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD473597
License Number StatePA
# 6
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberS9132
License Number StateTX
# 7
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number0101238278
License Number StateVA
# 8
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME146337
License Number StateFL
# 9
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME146337
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: