Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 5906 | NM |
NPI | 1013296912 |
---|---|
Provider Name | Jennifer Fowler |
First Address | Santa Fe, NM 87507-1834 |
Second Address | Santa Fe, NM 87507-1834 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/08/2011 |
Last Update Date | 09/08/2011 |