Healthcare Provider Details

I. General information

NPI: 1306807466
Provider Name (Legal Business Name): STACEY P FOWLER RN, LAT, ATC, LMBT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 03/08/2024
Certification Date: 03/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 WOODRIDGE CIR
HICKORY NC
28602-5599
US

IV. Provider business mailing address

1700 WOODRIDGE CIR
HICKORY NC
28602-5599
US

V. Phone/Fax

Practice location:
  • Phone: 704-408-2318
  • Fax:
Mailing address:
  • Phone: 704-408-2318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0823
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0417
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number333921
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: