Provider Demographics
NPI:1194228221
Name:FOWLER, LAURA JANE (ATC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JANE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 OAK AVE APT 46
Mailing Address - Street 2:
Mailing Address - City:GALT
Mailing Address - State:CA
Mailing Address - Zip Code:95632-1570
Mailing Address - Country:US
Mailing Address - Phone:540-641-1438
Mailing Address - Fax:
Practice Address - Street 1:145 N LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:GALT
Practice Address - State:CA
Practice Address - Zip Code:95632-1720
Practice Address - Country:US
Practice Address - Phone:540-641-1438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer