Basic Information
| Provider Information | |||||||||
| NPI: | 1548200116 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOWLER | ||||||||
| FirstName: | MARIECKEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 MEDICAL CIR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226013300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406671828 | ||||||||
| FaxNumber: | 5406671828 | ||||||||
| Practice Location | |||||||||
| Address1: | 9110 COLLEGE POINTE CT | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339193244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392082206 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 11/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084B0040X | 0101238278 | VA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Behavioral Neurology & Neuropsychiatry | 2084D0003X | 0101238278 | VA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Diagnostic Neuroimaging | 2084N0400X | 20637 | NH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | ME146337 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | MD473597 | PA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 0101238278 | VA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 001854467 | 01 | VA | MOUNTAIN STATE BCBS | OTHER | 010214851 | 05 | VA | MEDICAID | 196654 | 01 | VA | ANTHEM BCBS | OTHER | P00349159 | 01 | VA | RAILROAD MEDICARE | OTHER |