Provider Demographics
NPI:1780385575
Name:FOWLKES, TAKIARA
Entity type:Individual
Prefix:
First Name:TAKIARA
Middle Name:
Last Name:FOWLKES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6202 GIST AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-3608
Mailing Address - Country:US
Mailing Address - Phone:443-360-5527
Mailing Address - Fax:877-353-0384
Practice Address - Street 1:1848 REISTERSTOWN RD
Practice Address - Street 2:
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-1379
Practice Address - Country:US
Practice Address - Phone:443-360-5527
Practice Address - Fax:877-353-0384
Is Sole Proprietor?:No
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD29126225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist