Provider Demographics
NPI:1962893487
Name:FETTNER, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:FETTNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 MEDICAL BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110-1416
Mailing Address - Country:US
Mailing Address - Phone:239-449-3072
Mailing Address - Fax:877-334-1886
Practice Address - Street 1:1660 MEDICAL BLVD STE 200
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-1416
Practice Address - Country:US
Practice Address - Phone:239-449-3072
Practice Address - Fax:877-334-1886
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-06
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01595500225100000X
FL29997225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty