Provider Demographics
NPI:1396414389
Name:FERTITTA, CHARITY (PTA)
Entity Type:Individual
Prefix:
First Name:CHARITY
Middle Name:
Last Name:FERTITTA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:CHARITY
Other - Middle Name:GOMEZ
Other - Last Name:FERTITTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:7733 UPTON OXMOOR LN APT 209
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-3435
Mailing Address - Country:US
Mailing Address - Phone:225-485-2277
Mailing Address - Fax:
Practice Address - Street 1:2701 CHESTNUT STATION CT
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-6395
Practice Address - Country:US
Practice Address - Phone:800-335-1060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA04242225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY225200000XMedicaid