Healthcare Provider Details

I. General information

NPI: 1083551808
Provider Name (Legal Business Name): CAMERON BLAKE FORTENBERRY PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16100 CHENAL VALLEY DR
LITTLE ROCK AR
72223-4042
US

IV. Provider business mailing address

701 RAHLING RD APT 1402
LITTLE ROCK AR
72223-5292
US

V. Phone/Fax

Practice location:
  • Phone: 501-267-9554
  • Fax:
Mailing address:
  • Phone: 601-896-4333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA5036
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: