Provider Demographics
NPI:1043680002
Name:FOWLER, KECIA (DOM)
Entity Type:Individual
Prefix:
First Name:KECIA
Middle Name:
Last Name:FOWLER
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2735 7TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-6913
Mailing Address - Country:US
Mailing Address - Phone:727-710-4983
Mailing Address - Fax:831-480-5820
Practice Address - Street 1:3065 PORTER ST
Practice Address - Street 2:SUITE 105
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073-2231
Practice Address - Country:US
Practice Address - Phone:831-345-8399
Practice Address - Fax:831-480-5820
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-03
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16733171100000X
FLAP3866171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist