Provider Demographics
NPI:1104544709
Name:FORTNEY, KIMBERLY B (PTA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:B
Last Name:FORTNEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 E PARKINSON ST APT 2
Mailing Address - Street 2:
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665-1483
Mailing Address - Country:US
Mailing Address - Phone:608-792-1185
Mailing Address - Fax:
Practice Address - Street 1:403 E PARKINSON ST APT 2
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665-1483
Practice Address - Country:US
Practice Address - Phone:608-792-1185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3279-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant