Provider Demographics
NPI:1063103745
Name:FOWLER, CHERYL TORRANCE (LDOC, ABO, NCLEC)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:TORRANCE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:LDOC, ABO, NCLEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26206 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-4731
Mailing Address - Country:US
Mailing Address - Phone:352-584-1542
Mailing Address - Fax:352-796-4213
Practice Address - Street 1:7305 BROAD ST
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-3158
Practice Address - Country:US
Practice Address - Phone:352-796-6366
Practice Address - Fax:352-796-4213
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3058156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician