Healthcare Provider Details

I. General information

NPI: 1043819899
Provider Name (Legal Business Name): DANIELLE K FOWLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2020
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5025 ANN ARBOR RD
JACKSON MI
49201-8801
US

IV. Provider business mailing address

5416 N CANAL RD
DIMONDALE MI
48821-7700
US

V. Phone/Fax

Practice location:
  • Phone: 517-764-2000
  • Fax:
Mailing address:
  • Phone: 517-505-3768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502006214
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: