Healthcare Provider Details

I. General information

NPI: 1548294218
Provider Name (Legal Business Name): HEATHER L MACKEY-FOWLER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 QUAKER LN # C2-4
WARWICK RI
02886-0159
US

IV. Provider business mailing address

PO BOX 746088
ATLANTA GA
30374-6088
US

V. Phone/Fax

Practice location:
  • Phone: 401-233-5051
  • Fax:
Mailing address:
  • Phone: 312-733-9730
  • Fax: 773-866-8014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number228635
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD14673
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: