Healthcare Provider Details

I. General information

NPI: 1760955512
Provider Name (Legal Business Name): ELIZABETH C FONKEN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2019
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5988 STETSON HILLS BLVD
COLORADO SPRINGS CO
80923-3567
US

IV. Provider business mailing address

PO BOX 5718
KALISPELL MT
59903-5718
US

V. Phone/Fax

Practice location:
  • Phone: 719-574-3111
  • Fax: 719-574-2912
Mailing address:
  • Phone: 406-756-0134
  • Fax: 406-309-2579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTL0014475
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: