Provider Demographics
NPI:1194160630
Name:FOWLER, KIM Y (CLD, LMT, CNMT)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:Y
Last Name:FOWLER
Suffix:
Gender:F
Credentials:CLD, LMT, CNMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 QUINCE ORCHARD BLVD APT 13
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-1627
Mailing Address - Country:US
Mailing Address - Phone:301-820-0379
Mailing Address - Fax:
Practice Address - Street 1:805 QUINCE ORCHARD BLVD APT 13
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-1627
Practice Address - Country:US
Practice Address - Phone:301-820-0379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-09
Last Update Date:2017-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA175F00000X, 374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No175F00000XOther Service ProvidersNaturopath