Provider Demographics
NPI:1053015701
Name:FOWLER, CASSIDY RENEE
Entity type:Individual
Prefix:
First Name:CASSIDY
Middle Name:RENEE
Last Name:FOWLER
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 1:222 ROBERTA AVE
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-5950
Mailing Address - Country:US
Mailing Address - Phone:219-809-7480
Mailing Address - Fax:
Practice Address - Street 1:2401 VALLEY DR
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2520
Practice Address - Country:US
Practice Address - Phone:219-462-7173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37003682A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered