Provider Demographics
NPI:1023874161
Name:FOWLER, HEATHER CATHERINE (LDO, ABOC, NCLEC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:CATHERINE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:LDO, ABOC, NCLEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 HEARTHSTONE XING
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-5293
Mailing Address - Country:US
Mailing Address - Phone:770-598-5264
Mailing Address - Fax:
Practice Address - Street 1:12182 HIGHWAY 92
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-4885
Practice Address - Country:US
Practice Address - Phone:770-591-7721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO0002511156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician