Provider Demographics
NPI:1033981360
Name:FORTENBAUGH, MIRANDA ROSE
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ROSE
Last Name:FORTENBAUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 GINGRICH LN
Mailing Address - Street 2:
Mailing Address - City:DAUPHIN
Mailing Address - State:PA
Mailing Address - Zip Code:17018-9743
Mailing Address - Country:US
Mailing Address - Phone:717-440-6066
Mailing Address - Fax:
Practice Address - Street 1:940 WALNUT BOTTOM RD
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:PA
Practice Address - Zip Code:17015-6926
Practice Address - Country:US
Practice Address - Phone:717-249-0085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty