Provider Demographics
NPI:1962903294
Name:FORTUNE, PAULA L (MSPT)
Entity type:Individual
Prefix:MRS
First Name:PAULA
Middle Name:L
Last Name:FORTUNE
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9466 FOX RUN
Mailing Address - Street 2:
Mailing Address - City:BERRIEN CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49102-8710
Mailing Address - Country:US
Mailing Address - Phone:269-473-5655
Mailing Address - Fax:269-473-5555
Practice Address - Street 1:423 SYCAMORE ST STE 104
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2374
Practice Address - Country:US
Practice Address - Phone:269-687-2900
Practice Address - Fax:269-687-2903
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007396A225100000X
MI5501010993225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist