Provider Demographics
NPI:1639358419
Name:FISH, CHRISTINE ADRIENNE (PTA)
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:ADRIENNE
Last Name:FISH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5403 VICTORIA AVE
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3925
Mailing Address - Country:US
Mailing Address - Phone:563-327-0132
Mailing Address - Fax:
Practice Address - Street 1:2500 GRANT ST
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-5092
Practice Address - Country:US
Practice Address - Phone:563-359-9171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01033225200000X
IL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant