Provider Demographics
NPI:1710558622
Name:FORTENBERRY, MELISSA R
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:R
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 1:216 ENGLISH GARDENS PKWY
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-5680
Mailing Address - Country:US
Mailing Address - Phone:337-322-7744
Mailing Address - Fax:
Practice Address - Street 1:216 ENGLISH GARDENS PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-5680
Practice Address - Country:US
Practice Address - Phone:337-322-7744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-02
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05135225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist