=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104240571
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEGHAN FOWLER LAT, ATC, ITAT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2014
-----------------------------------------------------
Last Update Date | 12/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3737 BROCK RD
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30096-2724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-938-7762
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5540 GARENS WAY
-----------------------------------------------------
City | FLOWERY BRANCH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30542-2925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 0000001709
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT002669
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------