Basic Information
| Provider Information | |||||||||
| NPI: | 1083043285 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOWLIN | ||||||||
| FirstName: | ROSINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SIMONIAN | ||||||||
| OtherFirstName: | ROSINE | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 16539 LAKE BRIGADOON CIR | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336181146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135792212 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 145 E EDGEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338034014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636192809 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2013 | ||||||||
| LastUpdateDate: | 01/23/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Q00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist | 106S00000X | N |
No ID Information.