Provider Demographics
NPI:1205181203
Name:FORTENBERRY, AJA CENETTA
Entity Type:Individual
Prefix:MS
First Name:AJA
Middle Name:CENETTA
Last Name:FORTENBERRY
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 1:215 S WASHINGTON SQ
Mailing Address - Street 2:GARDEN LEVEL, SUITE A
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48933-1887
Mailing Address - Country:US
Mailing Address - Phone:517-285-9772
Mailing Address - Fax:
Practice Address - Street 1:215 S WASHINGTON SQ
Practice Address - Street 2:GARDEN LEVEL, SUITE A
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48933-1887
Practice Address - Country:US
Practice Address - Phone:517-285-9772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist