Provider Demographics
NPI:1811386881
Name:FOWLER, HEATHER (RD, LD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:FOWLER
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:RODMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:4665 RENWORTH AVE NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44714-1194
Mailing Address - Country:US
Mailing Address - Phone:419-610-6500
Mailing Address - Fax:419-423-5305
Practice Address - Street 1:4665 RENWORTH AVE NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44714-1194
Practice Address - Country:US
Practice Address - Phone:419-610-6500
Practice Address - Fax:419-423-5305
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-14
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.7354133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered