Healthcare Provider Details

I. General information

NPI: 1912597972
Provider Name (Legal Business Name): TANIA FOWLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2021
Last Update Date: 01/24/2021
Certification Date: 01/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4820 W ARTHINGTON ST
CHICAGO IL
60644-5205
US

IV. Provider business mailing address

4820 W ARTHINGTON ST
CHICAGO IL
60644-5205
US

V. Phone/Fax

Practice location:
  • Phone: 619-818-1005
  • Fax:
Mailing address:
  • Phone: 619-818-1005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberBC21500480
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: