Provider Demographics
NPI:1417732975
Name:FORTNER, BROOKE (DPT)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:FORTNER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 E 12TH AVE UNIT 206
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33605-3548
Mailing Address - Country:US
Mailing Address - Phone:305-975-3594
Mailing Address - Fax:
Practice Address - Street 1:1512 E 12TH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33605-3516
Practice Address - Country:US
Practice Address - Phone:305-975-3594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist