Healthcare Provider Details

I. General information

NPI: 1962788182
Provider Name (Legal Business Name): SUZANNE FOWLER L/ATC, CSCS, CEAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2011
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5949 W RAYMOND ST
INDIANAPOLIS IN
46241-4348
US

IV. Provider business mailing address

5074 PINE HILL DR
NOBLESVILLE IN
46062-7849
US

V. Phone/Fax

Practice location:
  • Phone: 317-390-5590
  • Fax:
Mailing address:
  • Phone: 317-607-7807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000214A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: