Healthcare Provider Details

I. General information

NPI: 1982577540
Provider Name (Legal Business Name): AUTIYANA FOWLKES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2025
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11979 FISHERS CROSSING DR
FISHERS IN
46038-2778
US

IV. Provider business mailing address

7425 WESTFIELD BLD
INDIANAPOLIS IN
46240-3056
US

V. Phone/Fax

Practice location:
  • Phone: 317-918-2689
  • Fax:
Mailing address:
  • Phone: 317-918-2689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: