Provider Demographics
NPI:1346888021
Name:FOWLER, ANASTASIA TATIANA
Entity Type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:TATIANA
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 1:6927 BIRDSEYE AVE NE APT 315
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-4556
Mailing Address - Country:US
Mailing Address - Phone:315-864-0006
Mailing Address - Fax:
Practice Address - Street 1:1570 WILMINGTON DR STE 220
Practice Address - Street 2:
Practice Address - City:DUPONT
Practice Address - State:WA
Practice Address - Zip Code:98327-8773
Practice Address - Country:US
Practice Address - Phone:206-453-4882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician