Provider Demographics
NPI:1336478205
Name:FOWLER, REGINA RYLEE
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:RYLEE
Last Name:FOWLER
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 1:1733 DAWSON ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-2326
Mailing Address - Country:US
Mailing Address - Phone:910-392-5806
Mailing Address - Fax:910-397-2867
Practice Address - Street 1:1733 DAWSON ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2326
Practice Address - Country:US
Practice Address - Phone:910-392-5806
Practice Address - Fax:910-397-2867
Is Sole Proprietor?:No
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000822573174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist