MEDICARE: REGINA RYLEE FOWLER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	000822573	NC

General Provider Information

NPI Number	:	1336478205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REGINA RYLEE FOWLER

Provider Business Mailing Address
First Line	:	1733 DAWSON ST
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-2326
Country	:	US
Telephone Number	:	910-392-5806
Fax Number	:	910-397-2867

Provider Business Practice Location Address
First Line	:	1733 DAWSON ST
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-2326
Country	:	US
Telephone Number	:	910-392-5806
Fax Number	:	910-397-2867

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/23/2009
Last Update Date	:	12/23/2009

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Directions to “ REGINA RYLEE FOWLER ” Practice Location

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