Healthcare Provider Details

I. General information

NPI: 1992990758
Provider Name (Legal Business Name): KRISTINA M FOWLER PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2007
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8043 SPYGLASS HILL RD
MELBOURNE FL
32940
US

IV. Provider business mailing address

8043 SPYGLASS HILL RD STE 102
MELBOURNE FL
32940-8563
US

V. Phone/Fax

Practice location:
  • Phone: 321-757-6899
  • Fax:
Mailing address:
  • Phone: 321-757-6899
  • Fax: 321-757-6859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT14780
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: