Healthcare Provider Details

I. General information

NPI: 1790123016
Provider Name (Legal Business Name): BRITTANY NICOLE FOWLER RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2013
Last Update Date: 06/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4218 AVENUE OF THE CITIES
MOLINE IL
61265-4544
US

IV. Provider business mailing address

4218 AVENUE OF THE CITIES
MOLINE IL
61265-4544
US

V. Phone/Fax

Practice location:
  • Phone: 309-762-0200
  • Fax: 309-762-0232
Mailing address:
  • Phone: 309-762-0200
  • Fax: 309-762-0232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1093468
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: