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General NPI Number Information
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NPI Number | 1053015701
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Entity Type | Individual
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Provider Name | CASSIDY RENEE FOWLER
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Gender | Female
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Dates
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Enumeration Date | 03/28/2023
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Last Update Date | 03/28/2023
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Provider Practice Location Address
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Address Line | 2401 VALLEY DR
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City | VALPARAISO
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State | IN
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Zip | 46383-2520
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Country | US
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Telephone | 219-462-7173
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Fax |
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Provider Business Mailing Address
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Address Line | 222 ROBERTA AVE
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City | MICHIGAN CITY
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State | IN
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Zip | 46360-5950
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Country | US
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Telephone | 219-809-7480
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Fax |
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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 | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 37003682A
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License Number State | IN
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