Provider Demographics
NPI:1013440601
Name:FOWLER, KRISTINA (SPECIAL EDUCATOR)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:
Last Name:FOWLER
Suffix:
Gender:F
Credentials:SPECIAL EDUCATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-4330
Mailing Address - Country:US
Mailing Address - Phone:631-828-5378
Mailing Address - Fax:
Practice Address - Street 1:16 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-4330
Practice Address - Country:US
Practice Address - Phone:631-828-5378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist