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General NPI Number Information
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NPI Number | 1043680002
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Entity Type | Individual
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Provider Name | KECIA FOWLER DOM
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Gender | Female
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Dates
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Enumeration Date | 10/03/2015
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Last Update Date | 01/09/2018
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Provider Practice Location Address
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Address Line | 3065 PORTER ST SUITE 105
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City | SOQUEL
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State | CA
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Zip | 95073-2231
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Country | US
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Telephone | 831-345-8399
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Fax | 831-480-5820
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Provider Business Mailing Address
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Address Line | 2735 7TH AVE N
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City | ST PETERSBURG
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State | FL
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Zip | 33713-6913
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Country | US
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Telephone | 727-710-4983
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Fax | 831-480-5820
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 16733
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | AP3866
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License Number State | FL
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