Healthcare Provider Details

I. General information

NPI: 1558512830
Provider Name (Legal Business Name): NICOLE FOWLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2008
Last Update Date: 10/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 5TH AVE
NEW YORK NY
10029-3119
US

IV. Provider business mailing address

160 W 97TH ST APT. 13B
NEW YORK NY
10025-6472
US

V. Phone/Fax

Practice location:
  • Phone: 212-426-3400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: