Provider Demographics
NPI:1740263763
Name:FOWLER, DELAINE ALYNN (PT)
Entity type:Individual
Prefix:DR
First Name:DELAINE
Middle Name:ALYNN
Last Name:FOWLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:DELAINE
Other - Middle Name:ALYNN
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1508 W INNES ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-2504
Mailing Address - Country:US
Mailing Address - Phone:704-630-9656
Mailing Address - Fax:704-630-9658
Practice Address - Street 1:1508 W INNES ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2504
Practice Address - Country:US
Practice Address - Phone:704-630-9656
Practice Address - Fax:704-630-9658
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9707225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC027KYOtherBCBS
NC027KYOtherBCBS
NC2507505DOtherMEDICARE PIN FOR 230179B (WHA)