Provider Demographics
NPI:1619427937
Name:FORTINBERRY, MELISSA (PT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:FORTINBERRY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1358
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:MS
Mailing Address - Zip Code:39666-1301
Mailing Address - Country:US
Mailing Address - Phone:601-248-8019
Mailing Address - Fax:
Practice Address - Street 1:709 ROBB STREET
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:MS
Practice Address - Zip Code:39666
Practice Address - Country:US
Practice Address - Phone:601-248-8019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT2169225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist