Healthcare Provider Details

I. General information

NPI: 1104240571
Provider Name (Legal Business Name): MEGHAN FOWLER LAT, ATC, ITAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2014
Last Update Date: 12/23/2022
Certification Date: 12/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 BROCK RD
DULUTH GA
30096-2724
US

IV. Provider business mailing address

5540 GARENS WAY
FLOWERY BRANCH GA
30542-2925
US

V. Phone/Fax

Practice location:
  • Phone: 404-938-7762
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0000001709
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT002669
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: