Provider Demographics
NPI:1104188333
Name:FOWLKES, TENICA
Entity Type:Individual
Prefix:
First Name:TENICA
Middle Name:
Last Name:FOWLKES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5535 S WILLIAMSON BLVD
Mailing Address - Street 2:SUITE 774
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-8311
Mailing Address - Country:US
Mailing Address - Phone:386-756-4395
Mailing Address - Fax:386-944-7202
Practice Address - Street 1:5535 S WILLIAMSON BLVD
Practice Address - Street 2:SUITE 774
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128-8311
Practice Address - Country:US
Practice Address - Phone:386-756-4395
Practice Address - Fax:386-944-7202
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE1000273225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant