1962103499 NPI number — CHRISTINA MARIE FOWLKES RN, IBCLC, DOULA

Table of content: CHRISTINA MARIE FOWLKES RN, IBCLC, DOULA (NPI 1962103499)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962103499 NPI number — CHRISTINA MARIE FOWLKES RN, IBCLC, DOULA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOWLKES
Provider First Name:
CHRISTINA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN, IBCLC, DOULA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962103499
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 450
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEONARDTOWN
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20650-0450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-556-9074
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25445 POINT LOOKOUT ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEONARDTOWN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20650-2065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-556-9074
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/13/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 374J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WL0100X , with the licence number: R247210 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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