Basic Information
| Provider Information | |||||||||
| NPI: | 1053552158 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORTNER | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | SUSAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DICKEY | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | SUSAN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 659 S SALISBURY BLVD | ||||||||
| Address2: | STE 1B | ||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218015458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108313226 | ||||||||
| FaxNumber: | 4106770883 | ||||||||
| Practice Location | |||||||||
| Address1: | 2895 HAMILTON BLVD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181046172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108413555 | ||||||||
| FaxNumber: | 6108413558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2009 | ||||||||
| LastUpdateDate: | 03/07/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT019678 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 40QA01309100 | NJ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.