Provider Demographics
NPI:1477707974
Name:FOWLER, MARY LEE ANN (DC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LEE ANN
Last Name:FOWLER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LEE ANN
Other - Last Name:MCCONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:135 PROFESSIONAL DR STE 105
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32082-7228
Mailing Address - Country:US
Mailing Address - Phone:270-210-9577
Mailing Address - Fax:
Practice Address - Street 1:11512 LAKE MEAD AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-1400
Practice Address - Country:US
Practice Address - Phone:270-210-9577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-11
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9853111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor